Blood Pressure Monitor Interest Form

* Required Information

VALLEY MEDICAL PHARMACY
630 Main Street, Brawley, CA 92227
Phone Number: (760) 344-6303
Fax Number: (760)344-6321

Patient's Name *

Date of Birth *

Patient's Email *

Street Address *

Street Address Line 2

City *

State

Zip Code *

Patient's Phone Number *

Pharmacy Insurance Information

Bin Number

PCN Number

Group Number

ID Number

I, , authorize Valley Medical Pharmacy to contact my provider on my behalf, for a prescription for a new blood pressure monitor.

Provider's Full Name *

Business Address

Business Address Line 2

City *

State

Zip Code *

Provider's Phone Number *

Provider's Fax Number

I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) the legal guardian of the patient. I authorize Valley Medical Pharmacy as applicable, to release my medical or other information to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf Valley Medical Pharmacy as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any co-sharing amounts, including co-pays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, upon receipt of such invoice.

Signature Of Patient/Employee/Legal Representative *

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VALLEY MEDICAL PHARMACY