The Cystic Fibrosis Services Pharmacy (CF Services)

  • I understand that all new prescriptions will be filled to my physician’s specifications and requested quantities, and, that it is my responsibility to be in agreement with my physician as to what is ordered from CF Services.
  • I understand that many medications will be sent in their original packaging and without child-resistant caps.
  • I understand that all prescriptions are filled according to my insurance plan guidelines.
  • If I have multiple insurance plans for coverage, all covered prescriptions will be dispensed according to the strictest insurance plan guidelines.
  • Medications dispensed and shipped by CF Services are non-returnable and payments for such medications are non-refundable.
  • I understand that upon receipt of an order, I am responsible for ensuring that CF Services receives payment.
  • I understand that CF Services reserves the right to post patient responsibility payments to the oldest outstanding account balance.
  • I understand that by providing CF Services with my credit card information, I authorize credit card charges at the time of sale.
  • I understand that any customer payment returned by CF Services’ financial institution for insufficient funds will result in a charge to my account, based upon our financial institutions charge.
  • CF Services allows its customers 60 days from the date an order is shipped to pay for outstanding orders. Any account that has an outstanding balance that is more than 60 days past due (regardless of payer) is considered a delinquent account and will be forwarded to the Account Services Department for collection investigation.
  • I understand that all future orders requested by delinquent account customers may be delayed pending collection investigation. CF Services reserves the right to interrupt service to customers whose accounts are delinquent.
  • I understand that I am responsible for updating CF Services with changes in my insurance coverage and billing/shipping address.
  • I understand that prices are subject to change without notice.
  • I understand that CF Services does not ship outside of the United States.
  • I understand that by filling a prescription at CF Services, I authorize the pharmacy to bill my insurance carrier(s) on my behalf and to accept Assignment of Benefits. This includes all Private Insurance Carriers, Medicare, Medicaid or other state-funded agencies under which a registered patient may be covered.
  • In the event that monies are paid directly to the subscriber or me for covered products and services provided by CF Services, I agree to forward these monies as well as a copy of the Explanation of Benefits (EOB) to CF Services in a timely fashion.
  • I understand that by filling a prescription at CF Services, I am assigning to CF Services all benefits payable to me under my current or future contract with my insurance carrier(s) for services and products provided by CF Services. I agree that any payments received relating to such services and products are held in trust for CF Services and should be immediately remitted to CF Services or its designee.

By Providing My Insurance Information and Filling Prescriptions At CF Services Pharmacy:

  • I Authorize and Instruct The Pharmacy To Bill On My Behalf

  • I Agree With The Above Pharmacy Terms and Conditions

Rev. 02/12/09