I understand and agree that all services rendered to me are charged directly to me, and that I am personally responsible for payment of all services and products. I understand that payment is due at time of service.
I understand that RX4Wellness is not in network with any insurance provider and cannot provide advice or assistance in filing insurance claims.
All services provided by the pharmacists of RX4Wellness are payable by, and the responsibility of, the patient and are not eligible for reimbursement by Medicare or Medicare supplemental plans. As non-enrolled providers, RX4Wellness and its staff are not eligible to file Medicare claims on behalf of the recipient of services; provide insurance documentation, billing support or advice. By accepting treatment/services at RX4Wellness, I understand that I am waiving any benefit that may be available to me under my Medicare or Medicare Supplemental plan. I consent and understand that payment is required at the time of service, is my sole responsibility, and charges are not eligible for submission.
Unsecure Email Communications
I consent to having medical information, appointment reminders, and general office communications sent to my email address (we cannot guarantee the security of messages delivered by email).
Collaborative Health Care
I understand RX4Wellness is a lifestyle education program run by the pharmacists of Hospital Discount Pharmacy. The health guidance discussed should be made known to and not override any conflicting instruction given by current healthcare providers. I will not discontinue or alter dosage of any prescription medication without consulting the prescribing medical provider. I will inform healthcare providers of any vitamins and supplements I begin taking.