Hotchkiss - Letter to Parents

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					The Salisbury Pharmacy Group
Salisbury Pharmacy
20 Main Street
P.O. Box 566
Salisbury, CT 06068
Phone: (860) 435-9388
Fax:     (860) 435-0258

April 1, 2010

RE: Pharmacy Services

Dear Parent(s),

Salisbury Pharmacy is pleased to provide daily service to The Hotchkiss School.

In order to provide us with your child’s current information, we have mailed you the attached forms to complete and
return to us in the enclosed self-addressed envelope prior to the beginning of EACH SCHOOL YEAR. Please also
include a photocopy (front & back) of your PRESCRIPTION insurance card(s). Salisbury Pharmacy accepts most
insurance plans and will make every effort to become an active participant in any plan in which we are not currently
enrolled. We ask that you complete these forms each year so our files can be updated with the new insurance/credit
card information.

Please keep in mind that many employers change insurance plans or carriers throughout the course of the year. It is
in everyone’s best interests that we are made aware of these changes so that there will be no interruptions or
problems with billing prescriptions for your child. Failure to provide current insurance coverage will result in the
pharmacy charging full retail price.

We recognize the school’s policy on outside medications being brought to the infirmary and offer a repackaging
service if required. If you have any prescriptions on hand that your child will need filled or repackaged, please
deliver them to the school infirmary and we will coordinate the actual dispensing with them.

We require that you provide us with your credit card information so that we may charge any prescription co-pays
and/or over-the-counter items directly to you. Please make sure that the card you provide is valid throughout the
entire school year. All information is kept confidential and secure. As with insurance cards, please keep us
informed of any credit card changes throughout the year so that we may maintain proper and efficient billing.
Failure to provide current credit card information will cause a delay in the delivery of the student’s medication.

In accordance with federal law, we have also included a copy of our Privacy Policies. Please sign, where indicated
on the enclosed forms, that you have received these policies.

Please contact me with any questions concerning billing, insurance or medications. I can be reached by phone at

We look forward to meeting you child’s pharmacy needs in the school year ahead.

Thank You,

Claudia Callinan, RPh.
Managing Pharmacist
Salisbury Pharmacy
The Salisbury Pharmacy Group             Student Name(s): Last, First, MI
Salisbury Pharmacy
20 Main Street
P.O. Box 566                       1.________________________________________
Salisbury, CT 06068
Phone: (860) 435-9388
Fax:     (860) 435-0258            2.________________________________________


                          ***PLEASE PRINT ALL INFORMATION CLEARLY***
 Name: Last, First                               Home Phone
 Billing Street Address                          Cell Phone
 P.O. Box                                        Work Phone
 City                                            Fax Number
 State & Zip Code                                e-mail

 1. Student Name                                 Date of Birth
 Social Security Number                          Allergies to Meds
 Phone/Fax                                       Male     /   Female

 2. Student Name                                 Date of Birth
 Social Security Number                          Allergies to Meds
 Phone/Fax                                       Male     /   Female

 3. Student Name                                 Date of Birth
 Social Security Number                          Allergies to Meds
 Phone/Fax                                       Male     /   Female

                                                          Visa            _____ Mastercard _____
    Method Of Payment                                     American Express _____ Discover   _____

    Card Number

    Expiration Date

    Name (As It Appears On Card)

    Signature Authorizing Payment

    Name Of Student(s)

Please Check One:

                  I have enclosed a copy (Front & Back) of my child’s PRESCRIPTION insurance card

                  My child has School Insurance

                  My child has NO PRECRIPTION INSURANCE Coverage

Attached is a copy of the Salisbury Pharmacy Group Privacy Notice. This is being provided to you under the
requirements of the Health Insurance Portability and Accountability Act (HIPAA). If you have any questions
about our policies, please contact us directly. We are required by this Act to request your signature upon
receipt of this document. Please sign your first and last name clearly on the line below. If your child is 18 or
older, he or she may sign as an adult.

I have received a copy of the Salisbury Pharmacy Group’s Privacy Notice.

Signature:_________________________________________________ Date: ______________

I authorize the release of my medical/prescription information to my parent/guardian
(for students over 18 years of age):

Signature:________________________________________________ Date: _______________