P4 Pharmacy will bill all appropriate agencies/insurances when possible, but the resident/patient or responsible party is ultimately accountable for any and all non-covered charges and co-payments.

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• Private Pay: P4 Pharmacy will bill the resident/patient

     or responsible party directly.

• Insurance: After insurance has been billed, the resident/patient or responsible party will be billed for all non-covered charges.

• Hospice: P4 Pharmacy will bill the hospice agency for all related charges.  The patient or responsible party will be billed for all non-covered charges.

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I agree to allow P4 Pharmacy to use the included credit card, bank account information or other method of payment to pay for pharmacy services as defined above.  I understand that this information will be stored securely and that suitable measures will be taken by the pharmacy to protect this information.