SIGNATURE LOG & ACKNOWLEDGEMENT

MEDROCK PHARMACY
12540 RACETRACK ROAD
TAMPA, FL 33626

PHONE: (727) 240-1341
FAX: (727) 240-1343

[email protected]

Your signature certifies that you received a service or item from MedRock Pharmacy. You are certifying that information contained herein is correct and the patient, for whom the prescription was written, is eligible for the benefits. You are also certifying that you have received the medication identified below. You hereby assign to this pharmacy provider any payment due pursuant to this transaction and authorize payment directly to this pharmacy provider.

You agree to allow this pharmacy or its designee to mail or deliver to you. The pharmacy will comply with all applicable and patient confidentiality laws.

In addition, you understand that if payment for this service, or item, will be from Federal and State funds, that any false claims, statements or documents, or concealment of material facts, may be prosecuted under applicable Federal and State laws. Furthermore, as required by State laws, you acknowledge receipt of an OFFER TO COUNSEL, and have accepted or refused counseling as indicated.

ALL OTHER THIRD PARTY PROGRAMS: Your signature certifies that this medication is NOT for the treatment of an on-the-job injury.

PRIVACY ACKNOWLEDGEMENT: Your signature acknowledges your receipt of our Notice of Privacy Practices. (This Notice describes how Medical Information about you may be used and disclosed and how you can get access to the information) the full privacy notice can be requested by emailing: [email protected].

If you have any questions regarding your medication(s) please consult with the pharmacist on the phone number provided above.