Long Term Care Credit Application

SICOMAC PHARMACY LTC

300 Sicomac Ave, Ste 4

Wyckoff, NJ 07481

Phone: (201) 891-0844

Fax: (201) 891-0038

Please Complete Carefully

Before any medication can be dispensed, this application must be completed in its ENTIRETY and signed by the Patient or RESPONSIBLE PARTY. It is your responsibility to keep your account information up to date. Please call (201) 891-0844 with any change of information.

Patient Information

First Name

Middle Name:

Last Name:

Date of Birth:

Phone:

Facility: (if applicable)

Address:

Apt. / Rm. #:

City:

State:

Zip Code:

RESPONSIBLE PARTY

First Name:

Middle Name:

Last Name:

Relationship:

Date of Birth:

Phone:

Email Address:

Mailing Address:

City:

State:

Zip Code:

PLEASE CHECK BOX WHERE BILLS ARE TO BE MAILED

PatientResponsible Party

Required To Be Completed: Credit Card

I understand this credit card will only be charged if this account is past due of 30 days.

Name:

Type:

Card Number:

Expiration Date:

Please check if you would like your credit card charged monthly. There is a 3% convenience fee for this option

By signing this application, I authorize Sicomac Pharmacy LTC to debit the above referenced credit card for all accounts past due 30 days or more.
I understand that I am financially responsible for all insurance copays. I also understand that not every medication is covered by insurance. If a medication costs $50.00 or more, Sicomac Pharmacy LTC will call me for authorization.

Name:

Date: