Medical Release - Guarantee of Payment

Patient's Name:(Required)

First Last

Patient's Date of Birth:(Required)

MEDICAL RELEASE

I authorize Freedom Pharmacy to release medical and billing information to the following (other than self or physician offices):

Name:

First Last

Phone:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:

Name:

First Last

Phone:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:

GUARANTEE OF PAYMENT

This is to certify that we, Freedom Pharmacy, will receive reimbursement from the patient OR guarantor listed below for prescription medications, over-the-counter products, co-pays, administration fees and any non-covered medications/products/services for the patient listed above for products/services rendered.

Choose one:(Required)

SEND BILLS TO PATIENT (skip to Patient Signature below)

SEND BILLS TO GUARANTOR (enter Guarantor's info below)

Name of Guarantor:

First Last

Address of Guarantor:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number:

Email:

Date(Required)