Clozaril – Golden Gate Pharmacy Services Inc

I am Currently(Required)

I am currently taking Brand name Clozaril

I am currently taking Generic Clozapine

I am currently taking Orally Disintegrating Clozapine (Fazaclo ODT)

I am currently taking Versacloz (liquid clozapine)

I am not taking any of the above

My total Daily dose is:(Required)

My Lab Frequence is:(Required)

Personal Information

Name(Required)

Date of Birth(Required)

Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Is this your shipping address?(Required)

Yes

No

Shipping Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Insurance Information

Insurance Type(Required)

Insurance Company(Required)

ID(Required)

Group #(Required)

PCN #(Required)

BIN #(Required)

Phone(Required)

Picture of Card Front

Max. file size: 32 MB.

Picture of Card Back

Max. file size: 32 MB.

Do you have other Insurance to Add?(Required)

Yes

No

Insurance Information #2

Insurance Type(Required)

Insurance Company(Required)

ID(Required)

Group #(Required)

PCN #(Required)

BIN #(Required)

Phone(Required)

Picture of Card Front

Max. file size: 32 MB.

Picture of Card Back

Max. file size: 32 MB.

Do you have other Insurance to Add?(Required)

Yes

No

Insurance Information #3

Insurance Type(Required)

Insurance Company(Required)

ID(Required)

Group #(Required)

PCN #(Required)

BIN #(Required)

Phone(Required)

Picture of Card Front

Max. file size: 32 MB.

Picture of Card Back

Max. file size: 32 MB.

Doctor Information

Doctor Name(Required)

Doctor Phone(Required)

Pharmacy Information

Pharmacy(Required)

Phone(Required)

If Eligible(Required)

If eligible, I would like Golden Gate Pharmacy Services to fill all my medications including Clozapine/Clozaril

If eligible, I would like Golden Gate Pharmacy Services to fill ONLY Clozapine/Clozaril

If you have a list of your medication, please upload it here:

Max. file size: 32 MB.

If you do not have a list, please type in your medications below:

Known Allergies:(Required)

YES

NO

If is Yes, List them here(Required)

Athelas

I am interested in getting information about the Athelas Home finger stick blood testing device(Required)

Athelas Home

YES

NO

If Applicable Only:

Name of Care Agency

Case Manager Name

Case Manager Phone

Printed name of individual filling out form(Required)

Relationship(Required)

Specify relationship(Required)

HIPPA

Do you already have an authorization from to release protected health information (PHI) to Golden Gate Pharmacy Services?(Required)

YES

NO

Please Upload File(Required)

Drop files here or

Max. file size: 32 MB.

Re: Patient Name(Required)

Date of Birth(Required)

to: Name of Representative(Required)

Representative Capacity(Required)

(Family member, advocate, Power of Attorney etc)

Address(Required)

Street Address Address Line 2 City State ZIP Code

II. Effective Period(Required)

Effective until(Required)

III. Extent of Authorization(Required)

information:(Required)

Mental health records

Alcohol/drug abuse treatment

Other

Other (please specify):(Required)

Signature of patient or Personal Representative(Required)

Date(Required)

Printed Name of Person Signing(Required)

First Last

If signed by the patient’s representative, explain your authority to act on behalf of the patient:(Required)

Acknowledgements

Automatic Refill Program(Required)

I have read and acknowledged Golden Gate Pharmacy Services Automatic Refill Program. Automatic Refill Program.(Required)

Packaging(Required)

I acknowledge that the standard packaging options are non-childproof. Please contact our pharmacy for childproof solutions.(Required)

Branded medication(Required)

I am requesting Golden Gate Pharmacy to fill Clozaril Branded medication for my prescriptions.(Required)

Test Claim(Required)

I understand Golden Gate Pharmacy Services will submit a test claim on my behalf to determine eligibility for this Program(Required)

Term of Services(Required)

I agree to Golden Gate Pharmacy Services Terms of Services. Terms of Services.(Required)

Athelas(Required)

I authorize Golden Gate Pharmacy Services to share HIPAA Information with Athelas(Required)

HIPAA(Required)

I have read and acknowledged Golden Gate Pharmacy Services HIPAA Privacy Policy. HIPAA Privacy Policy(Required)

Signature(Required)

How did you hear about this program?(Required)

CAPTCHA

Your Health Simply Delivered

Application for Clozaril Program

Personal Information

Insurance Information

Insurance Information #2

Insurance Information #3

Doctor Information

Pharmacy Information

Athelas

If Applicable Only:

HIPPA

Acknowledgements