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 owner of the credit card being used for payment, or by the cardholder’s Power of Attorney (if applicable). 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.

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

Name:

Type:

Card Number:

Expiration Date:

Yes By signing this application, I understand that I am financially responsible for all insurance copays and any over-the-counter items.

Yes 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:

This form must be signed by the owner of the credit card being used for payment, or by the cardholder’s Power of Attorney (if applicable), even if they are not the responsible party.