Bedside Delivery Patient Choice and Record of Delivery Form
PATIENT: COMPLETE SECTIONS A & B
SECTION A - To be completed prior to providing Bedside Delivery services
Patient First Name MI Patient Last Name
Date of Birth Age Gender: Male Female Home/Cell Phone Number
Home Address City State Zip Code
Do you have prescription insurance? Prescription Insurance Plan
Would you like to enroll in Walgreens Balance Rewards Program?
Email address
Caregiver Name (if available) Caregiver Relationship to Patient
By signing below:
I certify that I am: (a) the Patient and at least 18 years of age, (b) the parent or legal guardian of the minor Patient, (c) the legal guardian of the Patient, or (d) otherwise
legally authorized to sign for self . I hereby give my consent to use Walgreens Bedside Delivery Service. I understand that this service is an optional service provided as
a convenience to me. I understand I have the right to select any pharmacy to provide the medication ordered by my doctor and that this is my choice.
Patient’s Name (Please Print) Patient's, Parent's, Legal Guardian’s Signature Date
SECTION B - The following is only to be completed after you have received your Bedside Delivery discharge medication.
I have been offered a Pharmacist Consultation: Yes No If Yes: Accept Consult Decline Consult
By signing below:
I certify that I am: (a) the Patient and at least 18 years of age, (b) the parent or legal guardian of the minor Patient (c) the legal guardian of the Patient or
(d) otherwise legally authorized to sign for self
. I have received my discharge prescription(s) and have been offered a pharmacist consultation. I understand
that the discharge medications delivered should not be taken until I have been discharged from the facility.
AUTHORIZATION TO SUBMIT CLAIM AND ASSIGNMENT OF BENEFITS: I authorize Walgreens to submit a claim to the patient’s insurer for the item(s) deliv-
ered to the patient. In the event that Walgreens determines that the claim should be filed assigned to the patient’s insurer for payment, I hereby authorize
Walgreens to request on the patient’s behalf, and to collect directly, all public and private insurance coverage benefits due for the item(s) supplied to the patient
by Walgreens. In the event payments are made directly to anyone other than Walgreens, I agree that I will arrange for the payee to endorse to Walgreens all
checks for such payments.
RELEASE OF INFORMATION: I authorize Walgreens to use the patient’s health information, including the patient’s mental health, communicable disease, and
drug and alcohol abuse information, and disclose it to the patient’s insurer, as applicable, in order to determine and process the patient’s benefits related to the
item(s) delivered to the patient. I certify that I, as the patient or the patient’s designee, have received the above item(s) in perfect condition and have been trained
on how to use the item(s) properly. I have received a copy of this delivery ticket. Where possible, copays are collected at time of service. Amount owed may not
reflect deductible.
Patient’s Name (Please Print) Patient's, Parent's or Legal Guardian’s Signature Date
SECTION C - The following is only to be completed by the Walgreens BSD Pharmacy Technician after performing the BSD service.
By signing below:
I certify that I am the technician performing BSD services for the patient above and have provided the patient with: (a) the HIPAA Notice of Privacy
Practices and (b) Bedside Delivery discharge medication(s), and (c) have affixed the discharge medication prescription label(s) to the back of this
consent form.
BSD Pharmacy Technician Name BSD Pharmacy Technician Signature Date
Check One: Bedside Delivery Discharge Date:
Express Pick up at Walgreens Discharge Time: _______________________ am/pm Room #:
CONFIDENTIAL HEALTH INFORMATION: Healthcare information is personal information related to a person’s healthcare. It is being faxed to you after the appropriate authorization or under circum-
stances that don’t require authorization. You are obligated to maintain it in a safe, secure and confidential manner. Redisclosure of this information is prohibited unless permitted by law or appropriate
customer/patient authorization is obtained. Unauthorized redisclosure or failure to maintain confidentiality could subject you to penalties described in federal and state laws.
IMPORTANT
WARNING: This message is intended for the use of the person or entity to whom it is addressed and may contain information that is privileged and confidential, the disclosure of which is
governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any
dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message in error, please notify us immediately.
Payment:
Credit Card Cash
Check
Yes
No
Yes
No
NOTE: Email address is required to enroll in Walgreens Balance Rewards Program
Room #: _________
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