Patient Forms
Prescription and Refill Orders
Your prescriber must send a valid prescription to our pharmacy via their preferred means. Please note, certain controlled substance medications cannot be faxed to the pharmacy by law and a paper copy of these prescriptions must be sent to the pharmacy.
Once a valid prescription is on file, you may call into our pharmacy at any time to place your order and setup a shipment.
At any time, you can call the pharmacy to speak with a staff member. Please have the following information available: medication name, your first and last name, address, date of birth, daytime phone number
Treatment Advocate will call before refill is due to schedule a delivery of your refill or you may call your Treatment Advocate directly.
Your prescription may be filled with a generic equivalent substitution based on state law, equivalency rating and in accordance with company policy. Please ask a pharmacist if you have any questions or concerns.
Contact your Treatment Advocate directly or call the pharmacy at 800-540-4700 and we will transfer the prescription to the pharmacy of your choice.
Emergency Preparedness
- Where can I find recommendations and information for preparing for an emergency?
- Where can I find a list of people, companies, and organizations that can assist me if there is an emergency?
- What kind of supplies or things should I have set aside?
- You should develop a realistic preparedness plan in advance of any emergency or disaster. You should have at least a 72-hour emergency supply of food, water, medications and necessary medical supplies, a portable radio, flashlight and batteries. If you have pets you should have supplies for them.
- Select a family member or friend who lives out of the immediate area to act as a contact person for you and your family. More often than not it is easier to make a call outside the area following a disaster. Make sure you give this person’s name and phone number to Premier Pharmacy Services. We may need to call this person to try and locate you after the emergency so that the necessary services may be provided to you.
Adverse Reactions and Concerns
Contact Us: 800-540-4700
Medication Recalls
Contact Us: 800-540-4700
Patient Welcome Packet
Dear Patient:
Welcome to Premier Pharmacy Services. We would like to welcome you to our pharmacy. We will work closely to coordinate your care with your physician. Our organization is proud that you have chosen us to handle your health care needs. Our most important asset is you, our customer. Premier Pharmacy Services was founded in 1979, with the tradition of providing exceptional materials and services to every patient, doctor, professional and other health care providers in the community. Premier Pharmacy Services is a specialty and home infusion pharmacy. We are dedicated to providing the highest quality prescription services throughout the United States. All of our personnel are trained with an emphasis on caring for your personalized needs.
Should you need to order medication, you may do so by calling 800‐540‐4700. We are available 24 hours Monday thru Sunday. We have deliveries Monday thru Sunday. We do offer after hour delivery in the event of emergencies. Our phone number during business and after hours is 800‐540‐4700. If you should have any questions regarding billing, you can reach our billing office between the hours of 8AM to 8PM Monday through Friday at 800‐540‐4700. Every effort will be made to provide delivery of medication at your convenience.
MISSION AND VALUES
Our mission is to promote optimal outcomes for persons enduring debilitating diseases while delivering industry‐leading patient care with integrity, compassion and excellence.
ACCEPT OR REFUSAL OF MEDICAL CARE
We realize that all of our patients have the right to make decisions regarding their own medical care. These rights would include the right to accept service/care, or refusal of service/care. We at Premier Pharmacy Services will provide upon request, information regarding the patient’s right to prepare an Advance Directive/Living Will. This is a document that states the wishes of a person if he/she is unable to speak due to a sudden medical condition. We shall honor any patient’s Advance Directive. It is up to the patient to see that we receive a copy of this form.
YOUR RIGHTS AND RESPONSIBILITIES
You and Premier Pharmacy Services are partners in your health care plan. To ensure the finest care possible, you must understand your role in your patient management program.
As a patient of Premier Pharmacy Services, you have the RIGHT to:
- Be fully informed in advance of receiving services, as well as any modifications to the plan of care, and of your rights and
responsibilities. - Be informed in advanced about care/services provided and your financial responsibility.
- Be informed about the scope of services provided by Premier Pharmacy Services, specific limitations on those services, and assistance with any transfer of appropriate care or service to another organization.
- Participate in the development and periodic revision of the plan of care.
- Make decisions to accept, refuse or withdraw medical care after the consequences of refusing care or treatment are fully presented.
- Be informed of patient rights under the state law to formulate an Advance Directive, if applicable.
- Be treated with respect, compassion, consideration, and recognition of patient dignity and individuality individual. Your care will include consideration of the psycho-social spiritual cultural and economic variables that influence your perception of illness.
- Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property.
- Voice grievance/complaints regarding treatment or lack thereof, or recommended changes in policy, personnel, or care/services without restraint, interference, coercion, discrimination, or reprisal.
- Have grievance/complaint regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated.
- Receive a response to a written complaint concerning services rendered upon request and in a timely manner.
- Confidentiality and privacy of all information contained in the patient record and of Protected Health Information (PHI).
- Be advised on Premier Pharmacy Services’ procedures regarding the disclosure of clinical records.
- Choose a healthcare provider, including a physician or other licensed practitioner with prescribing authority.
- Receive appropriate care without discrimination in accordance with prescriber’s orders, if applicable.
- Be informed of any financial benefit to Premier Pharmacy Services if services are transferred to another party.
- Receive communication regarding our care in a language or form that is readily understood by you, either by interpreter or in writing.
- Have personal health information shared with the program offered by Premier Pharmacy Services only in accordance with state and federal law.
- Identify staff members, including their job title, and to speak with a staff member’s supervisor if requested
- Speak to a health professional.
- To receive information regarding the patient management program.
- Decline participation or opt-out of the patient management program at any point in time by calling 800-540-4700 or emailing info@premierpharmacy.com.
- Have your family (including significant other) and/or surrogate decision maker participate in the facilitation of your care and to exercise your rights if you are unable to do so
- Receive prompt and appropriate treatment for which you are eligible.
- Express your concerns regarding the timeliness of services and devices rendered.
- Discuss your eligibility and entitlement for programs and services with a staff member.
- Be given the opportunity to address issues with a staff member.
- Be involved, in discussions and resolutions of any conflicts or ethical issues related to your care.
- Be informed of any experimental or investigational studies which involve your care, and maintain the right to refuse any participation in these activities.
- Receive consultation. Pharmacist is available at 626-626-9400 or 800-540-4700
- Be assisted with the best medical capabilities available to date in order to assist with any pain which you might experience.
- Request and receive any records with Premier Pharmacy for me to examine.
- Be informed and supplied all documented consent forms, if you agree to participate in any educational classes which are filmed or recorded within our organization.
- Premier Pharmacy Services dispenses generic equivalent if available for all prescriptions if allowed. You have the right to request for the prescription to be dispensed as written by your prescriber.
- Be fully informed of one’s responsibilities.
Each patient of Premier Pharmacy Services you have the responsibility:
- To treat the staff with the same respect and courtesy, you wish to be treated with.
- To submit any forms that is necessary to receive services and participate in the Patient Management Program.
- To give accurate clinical and contact information, and notify the patient management program of any changes in this information.
- Of your actions if you refuse treatment or do not follow prescriber or pharmacist’s instructions.
- To notify your physician when you are feeling ill or encounter any unusual physical, mental stress, or sensations.
- To notify Premier Pharmacy Services if you will not be home for a scheduled delivery or pick up.
- To notify Premier Pharmacy Services prior to changing your place of residence or your telephone number.
- To notify Premier Pharmacy Services if you become hospitalized.
- To inform one of our staff members of your health history, including past hospitalizations, illnesses, injuries, etc.
- To provide accurate information concerning your present health, medication, allergies.
- To help assist in developing and maintaining a safe environment as well as participating in the developed/update of home care plan of service/treatment.
- To notify Premier Pharmacy for any additional information concerning issues which you do not understand.
- To notify Premier Pharmacy Services of any concerns about the care or services provided.
- To notify Premier Pharmacy immediately if you acquire any infectious disease during the time you are receiving services and/or care from us. (Except where exempted by law)
- To remove refrigerated items and let stand at room temperature one hour prior to use or as instructed by Nurse or Pharmacist.
- To inspect medication for leaks, change in color or presence of particles prior to each administration.
- Notify your treating provider of your participation in the patient management program.
- To call our pharmacy if:
- You accidentally waste or miss a dose of your medication
- You find any damaged supplies
- Administration of the first lifetime dose of a new medication should be discussed with our pharmacist and/or nurse.
DRUG AND DISEASE INFORMATION AND PATIENT FORMS
To learn more your condition and treatment, visit our website at www.premierpharmacy.com and select SPECIALTIES dropdown.
To access patient forms relevant to your treatment, visit our website at www.premierpharmacy.com and select PATIENT, then EXITING PATIENTS.
HOW TO CONTACT POISON CONTROL CENTER
Get help from Poison Control right away if you suspect a poisoning. Free, expert help is available online and by phone, 24/7. Contact: 800‐222‐1222 Website: www.poison.org
HOW TO DISPOSE OF UNUSED AND/OR EXPIRED MEDICINES
Many community based drug “take back” programs offer the best solution to disposing unused and/or expired medicines. Otherwise, almost all medicines can be thrown in the household trash with the precautions described below:
Step 1: Remove medicine from the original container and mix them with an undesirable substance, such as used coffee grounds, dirt, or kitty litter.
Step 2: Place the mixture in a sealable bag, empty can or other container that prevents the drug from leaking or breaking out of the garbage bag.
Step 3: Scratch out identifying information on the prescription label to make it unidentifiable. This will help protect your identity and the privacy of your personal health information.
For additional information about proper medication disposal, please visit our website or www.safe.pharmacy
SHARPS DISPOSAL
The U.S. Food and Drug Administration recommend a two-step process for properly disposing of used needles and other sharps. Do not reuse sharps disposal containers.
Step 1: Place all needles and other sharps in a sharps disposal container immediately after they have been used.
Step 2: Dispose of used sharps disposal containers according to community guidelines. Sharps container disposal vary depending on where you live. Check with your local trash removal services or health department to find out the proper disposal method in your area:
- Drop box or supervised collection sites
- Household hazardous waste collection sites
- Mail back programs
- Residential special waste pick-up services
Note: Overfilling a sharps disposal container increases the risk of accidental needle-stick injury. When you sharps container is about three quarters (3/4) full, follow community guidelines for proper disposal of sharps disposal container.
Be prepared when leaving home. Always carry a small, travel-sized sharps disposal container in case other options are not available.
For additional information about safe needle disposal, call 800-643-1643.
HOW TO FILE A COMPLAINT
In the event your complaint remains unresolved with Premier Pharmacy Services or if you have reason to believe that we have violated your privacy rights, or disagree with a decision regarding your protected health information, you have the right to file a complaint with us, URAC, The Accreditation Commission for Health Care (ACHC), The Compliance Team, or the Board of Pharmacy.
- Premier Pharmacy Services: 800-540-4700
- URAC: https://www.urac.org/file-a-complaint
- ACHC: www.achc.org or 855-937-2242
- The Compliance Team: www.thecomplianceteam.org or 1-888-291-5353
- Board of Pharmacy: www.pharmacy.ca.gov
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. Please read it carefully.
Our Duty to Safeguard Your Protected Health Information (PHI)
We are committed to preserving the privacy and confidentiality of your health information. We are required by certain state and federal regulations to implement policies and procedures to safeguard your health information. We are required by state and federal regulations to abide by the privacy practices described in this notice, including any future revision that we may make to notice as they become necessary or as authorized by law.
Individually identifiable information about your past, present or future of your health condition, the provision of health care to you or payment for the health care services you received is considered protected health information (PHI). Accordingly, we are required to provide you with this notice that contains information regarding our privacy practices to explain how, when and why we may use or disclose your PHI and your rights and our obligations regarding any such uses or disclosures, except in specified circumstances. In specified circumstances we must use or disclose only the minimum amount of PHI necessary to accomplish the intended purpose of such information.
How We May Use and Disclose Your Protected Health Information
We have a limited right to use and/or disclose your protected health information (PHI) for purposes of treatment, payment, or other health related services. For other uses and disclosures, you must give Premier Pharmacy Services your written authorization to release your PHI unless the law permits or requires us to make the use or disclosure without your authorization.
TREATMENT: We may use and disclose PHI about you to provide you with medical treatment, medications, or services and to coordinate your care. For example, we may disclose your PHI to hospitals, physicians, counselors, and any other entity involved in your care. We may use and disclose PHI to contact you by mail, email, or phone to remind you that you have an upcoming prescription due for refill. We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
PAYMENT: We may use and disclose PHI about you so that the treatment and services you receive from us may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may provide information to your health insurance company so that the insurer will reimburse you or us, we may need to obtain prior approval from your insurer for care, and we may use and disclose your health information to determine whether you are eligible for health benefits.
HEALTH CARE OPERATIONS: We may use and disclose PHI about you for health care operations purposes, including proper administration of records, evaluation of quality of treatment, assessing the care and outcome of your case and others like it, arranging for legal services, and providing appointment reminders. For example, we may use PHI to evaluate the performance of our staff. We also may make disclosures of limited PHI incidental to permitted disclosures.
FAMILY MEMBERS/DISASTER NOTIFICATION: Unless you object, we may disclose PHI to a family member or other individual
who is involved in your medical care or payment for your care. In addition, we may disclose PHI about you to an entity
assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
REQUIRED BY LAW: We may use and disclose your PHI when required to do so to comply with federal, state or local law.
TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose your PHI if we, in good faith, believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of you, the public, or another person.
TO BUSINESS ASSOCIATES: We may disclose your PHI to third parties known as “Business Associates” that perform various activities (e.g. legal services, delivery of goods) for us and that agree to protect the privacy of your PHI.
SPECIFIED GOVERNMENT FUNCTIONS: In certain circumstances, we may use and disclose your PHI for specialized government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations, and inmates or law enforcement custody.
WORKERS’ COMPENSATION: We may disclose your PHI as necessary to comply with laws related to workers’ compensation or similar programs.
PUBLIC HEALTH AND SAFETY PURPOSES: We may use and disclose PHI about you for public health activities as authorized by law, such as disclosures to prevent or control disease, injury or disability, to report reactions to medications or problems with products, to provide notices of recalls of products, and to report vital statistics, disease information, and similar information to public health authorities.
REPORT ABUSE, NEGLECT OR DOMESTIC VIOLENCE: As authorized by law, we may disclose PHI to government authorities if we believe an individual is the victim of abuse, neglect, or domestic violence and certain conditions are met.
HEALTH OVERSIGHT ACTIVITIES: We may disclose PHI to a health oversight agency for certain activities including audit, investigations, inspections, licensure or disciplinary actions, or civil, administrative, and criminal proceedings. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: We may disclose your PHI in response to a court or administrative order, subpoena, or discovery request, or other lawful processes.
LAW ENFORCEMENT: We may disclose your PHI to law enforcement officials as permitted or required by law. We may also disclose your PHI in response to a court order, subpoena, warrant, or other similar written request from law enforcement officials.
CORONERS, MEDICAL EXAMINERS, OR FUNERAL DIRECTORS: We may disclose PHI to coroners, medical examiners, or funeral directors, as authorized by law, so they can carry out their duties.
JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: We may disclose your PHI in response to a court or administrative order, subpoena, or discovery request, or other lawful processes.
LAW ENFORCEMENT: We may disclose your PHI to law enforcement officials as permitted or required by law. We may also disclose your PHI in response to a court order, subpoena, warrant, or other similar written request from law enforcement officials.
CORONERS, MEDICAL EXAMINERS, OR FUNERAL DIRECTORS: We may disclose PHI to coroners, medical examiners, or funeral directors, as authorized by law, so they can carry out their duties.
RESEARCH: We may, under certain circumstances, use and disclose your PHI for research. We may, under certain circumstances, use and disclose your PHI for research.
ORGAN, EYE OR TISSUE DONATION: We may use and disclose your PHI to organ procurement organizations or other entities
engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of facilitating the
donation and transplantation.
LIMITED DATA: We may identify data that identifies you from a set of data and use and disclose this data set for research, public health and health care operations, provided the recipients of the data set agree to keep it confidential.
HEALTH INFORMATION EXCHANGES: We may participate in one or more Health Information Exchanges and may electronically share your PHI for treatment, payment, healthcare operations and other permitted purposes with other participants in the HIE. HIEs allow your health care providers to efficiently access and use your PHI as necessary for treatment and other lawful purposes.
FAMILY MEMBERS/DISASTER NOTIFICATION: Unless you object, we may use or disclose your PHI to notify or assist in notifying a family member, personal representative, or any other person responsible for your medical care or payment for your care regarding your location, general condition, or death. We may also disclose your PHI to disaster relief organizations so that your family or other persons responsible for your care can be notified of your location, general condition, or death.
CORRECTIONAL INSTITUTION: We may disclose your PHI to the institution or its agents to assist them in providing your health care, protecting your health and safety of the health and safety of others if you are or become an inmate of a correctional institution.
SPECIFIED GOVERNMENT FUNCTIONS: In certain circumstances, we may use and disclose your PHI for specialized government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations, and inmates or law enforcement custody.
Authorization to Use or Disclose Protected Health Information
For uses and disclosures of your PHI beyond the above expected purposes in this Notice, we are required to have your written authorization, except otherwise required or permitted by law. You have the right to revoke an authorization at any time to stop future uses or disclosures of your information except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing. We may disclose a limited amount of your PHI if we provide you with an advance verbal or written notice and you do not object to such release or such release is not otherwise prohibited by law. However, in an emergency situation and you are unable to object, disclosure may be made if it is consistent with all prior expressed wishes and disclosure determined to be in your best interest. When disclosure is made based upon an emergency situation, we will only disclose PHI relevant to the person’s involvement to your care. You will be informed and given an opportunity to object to further disclosures of such information as soon as you able to do so. State and federal laws and regulations in some instances either require or permit us to use or disclose your PHI without your consent or authorization.
Your Rights Regarding Your Protected Health Information
You have the following rights concerning the use or disclosure of your PHI. If another individual is appointed as your legal guardian or authorized by law to make healthcare decisions for you, that individual may exercises any of the below listed rights.
RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES OF YOUR PHI: You have the right to request that we limit how we use or disclose your PHI for treatment, payment, or health care services. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment of your services. Should you place a restriction on the use of disclosure of your PHI, you must submit such request in writing.
RIGHT TO INSPECT AND COPY YOUR HEALTH AND BILLING RECORDS: You have the right to inspect and copy your PHI. To inspect and/or copy your PHI, you must submit a written request to Premier Pharmacy Services.
RIGHT TO AMEND OR CORRECT YOUR PHI: You have the right to request that your PHI be amended or corrected if you have reason to believe that certain information is incomplete of incorrect. You have the right to make such request of us for as long as we maintain your protected health information. Your request must be submitted to us in writing.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about your health matters in a certain way. We will agree with your request as long as if it is reasonable for us to do so
RIGHT TO REQUEST AN ACCOUNTING OF DISCLOSURES: You have the right to request an accounting of disclosures we make of your PHI for the purposes other than treatment, payment, or health care operations. We will provide you one account per 12‐month period free of charge, but you may be charged for the cost of any subsequent accountings. We will notify you in advance of the cost involved, and you may choose to withdraw or modify your request at that time.
RIGHT TO OBTAIN A COPY OF THIS NOTICE: You have the right to get a paper copy of our current Notice at any time. You may do so calling to request a copy at 800‐540‐4700.
RIGHT TO NOTIFICATION OF BREACH: You have the right to be notified in the event there is a breach of your unsecured PHI as defined by HIPAA.
If You Believe Your Rights Have Been Violated
If you believe we have violated your privacy rights, you can file a complaint with us or with the U.S. Department of Health and Human Services for Civil Rights. To file a complaint with us, submit your complaint in writing to our Privacy Office. To file a complaint with the U.S. Department of Health and Human Services for Civil Rights, send a letter to 200 Independence Ave., S.W., Washington, D.C. 20201, calling 877‐696‐6775, or visiting www.hhs.gov/ocr/privacy/hipaa/compliants.
Changes to this Notice
We reserve the right to make changes to this Notice as permitted by law and to make the revised Notice effective for PHI we already have about you as well as any information we receive in the future, as of the effective date of the revised Notice. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Upon request to the Privacy Office, Premier Pharmacy Services will provide a revised Notice to you.
Contact Us by Mail or Phone
Premier Pharmacy Services
Attn: Privacy Office
410 Cloverleaf Drive
Baldwin Park, CA 91706
Phone: 800‐540‐4700
Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).
- A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
- A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
- A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges.
- A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or any other Federal procurement or non-procurement programs.
- A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
- A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
- A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
- A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards.
- A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
- A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
- A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR § 424.57 (c) (11).
- A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.
- A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
- A supplier must maintain and replace at no charge or repair cost either directly, or through a service contract with another company, any Medicare-covered items it has rented to beneficiaries.
- A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
- A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.
- A supplier must disclose any person having ownership, financial, or control interest in the supplier.
- A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
- A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
- Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
- A supplier must agree to furnish CMS any information required by the Medicare statute and regulations.
- All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services (except for certain exempt pharmaceuticals).
- All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
- All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
- All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
- A supplier must meet the surety bond requirements specified in 42 CFR § 424.57 (d).
- A supplier must obtain oxygen from a state-licensed oxygen supplier.
- A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR § 424.516(f).
- A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.
- A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.
State Board of Pharmacy Directory
State | Website | Phone Number |
---|---|---|
AL | www.albop.com | 205-981-2280 |
AK | www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/BoardofPharmacy.aspx | 907-465-2550 |
AZ | https://pharmacy.az.gov/ | 602-771-2727 |
AR | www.pharmacyboard.arkansas.gov/ | 501-682-0190 |
CA | www.pharmacy.ca.gov/ | 916-574-7900 |
CO | www.colorado.gov/pacific/dora/Pharmacy | 303-894-7800 |
CT | portal.ct.gov/DCP/Drug-Control-Division/Commission-of-Pharmacy/The-Commission-of-Pharmacy | 860-713-6070 |
DE | www.dpr.delaware.gov/boards/pharmacy/ | 302-744-4500 |
FL | floridaspharmacy.gov/ | 850- 488-0595 |
GA | www.gbp.georgia.gov/ | 404-651-8000 |
HI | www.cca.hawaii.gov/pvl/boards/pharmacy/ | 808-586-2695 |
ID | www.bop.idaho.gov/ | 208-334-2356 |
IL | www.idfpr.com/profs/pharm.asp | 800-560-6420 |
IN | www.in.gov/pla/pharmacy.htm | 217- 558-1422 |
IA | www.pharmacy.iowa.gov/ | 515-281-5944 |
KS | www.pharmacy.ks.gov/ | 785-296-4056 |
KY | www.pharmacy.ky.gov/ | 502-564-7910 |
LA | www.pharmacy.la.gov/ | 225-925-6496 |
ME | https://www.maine.gov/ | 207-624-8686 |
MD | www.health.maryland.gov/pharmacy/Pages/index.aspx | 410-764-4755 |
MA | www.mass.gov/orgs/board-of-registration-in-pharmacy | 800- 414-0168 |
MI | www.michigan.gov/lara/ | 517-373-8068 |
MN | www.mn.gov/boards/pharmacy/ | 651-201-2825 |
MS | www.mbp.ms.gov/Pages/default.aspx | 601-899-8880 |
MO | www.pr.mo.gov/pharmacists.asp | 573-751-0091 |
MT | www.boards.bsd.dli.mt.gov/pha | 406-841-2371 |
NE | https://dhhs.ne.gov/licensure/Pages/Pharmacy-Professions.aspx | 402-471-2118 |
NV | https://bop.nv.gov | 775-850-1440 |
NH | https://www.oplc.nh.gov/board-pharmacy | 603-271-2350 |
NJ | https://www.njconsumeraffairs.gov/renewals/Pages/Pharm.aspx | 973-504-6450 |
NM | www.rld.state.nm.us/boards/Pharmacy.aspx | 505-222-9830 |
NY | http://www.op.nysed.gov/prof/pharm/ | 518-474-3817 Ext. 130 |
NC | www.ncbop.org/ | 919-246-1050 |
ND | www.ndboard.pharmacy/ | 701-328-9535 |
OH | www.pharmacy.ohio.gov/ | 614-466-4143 |
OK | www.ok.gov/pharmacy/ | 405-521-3815 |
OR | www.oregon.gov/Pharmacy/pages/index.aspx | 971-673-0001 |
PA | www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Pharmacy | 717-783-7156 |
RI | www.health.ri.gov/licenses/detail.php?id=275/ | 401-222-2837 |
SC | https://llr.sc.gov/bop/ | 803-896-4707 |
SD | www.pharmacy.sd.gov/ | 605-362-2737 |
TN | https://www.tn.gov/health/health-program-areas/health-professional-boards/pharmacy-board.html | 615-741-2718 |
TX | www.pharmacy.texas.gov/ | 800-821-3205 |
UT | www.dopl.utah.gov/licensing/pharmacy.html | 801-530-6628 |
VT | https://sos.vermont.gov/pharmacy/ | 802-828-5032 |
VA | www.dhp.virginia.gov/pharmacy/ | 804-367-4456 |
WA | www.doh.wa.gov/LicensesPermitsandCertificates/ProfessionsNewReneworUpdate/PharmacyCommission | 360-236-4946 |
WV | www.wvbop.com/ | 304-558-0558 |
WI | www.dsps.wi.gov/pages/BoardsCouncils/Pharmacy/Default.aspx | 608-266-2112 |
WY | https://pharmacyboard.wyo.gov/ | 307-634-9636 |
Patient Consent Acknowledgement & Agreement
Please read, sign, date, and return this form to Premier Pharmacy Services as soon as possible using the provided self-addressed stamped envelope.
HIPAA Privacy Practices and Release of Medical Records Acknowledgement: You acknowledge that you have received and reviewed a copy of the Notice of Privacy Practices provided by Premier Pharmacy Services in the Patient Welcome Packet and you authorize Premier Pharmacy Services to release of any medical or other information necessary to provide therapy, services, or products. You also request payment of government benefits either to yourself or to the third party who accepts assignments according to the section titled “Assignment of Benefits.”
Patient Rights and Responsibilities Acknowledgement: You acknowledge that you have received and reviewed a copy of Patient Rights and Responsibilities provided by Premier Pharmacy Services in the Patient Welcome Packet.
Enrollment into the Patient Management Program: You acknowledge that you have been enrolled into Premier Pharmacy Services’ Patient Management Program, and understand you may opt-out and any time.
Consent for Professional Services: You are agreeing to receive pharmacy services from Premier Pharmacy Services and our pharmacists and nurses. While providing services, you authorize Premier Pharmacy Services to work with your other healthcare providers on your behalf.
Assignment of Benefits: You authorize payment for medication benefits to Premier Pharmacy Services for the therapy, services, and products supplies by Premier Pharmacy Services if the service or product provided are payable under a Medicare or other applicable government or commercial provided benefit.
Financial Responsibility: You understand that if no insurance coverage exists for a product or service or the insurance provider fails to pay, you are financially responsible for the incurred charges.
Consent for Text Messaging Service: You are agreeing to receive text messages sent by Premier Pharmacy Services’ via automated technology to the mobile phone number provided. Message and data rates may apply. You may text STOP to 97595 to opt-out (you will be sent a confirmation message) or call 800-540-4700.
By signing below, you are indicating that Premier Pharmacy Services has provided you the above disclosures, and that you are consenting to receive pharmacy services as a patient from Premier Pharmacy Services.
Patient Rights and Responsibilities
Each patient of Premier Pharmacy Services you have the right to:
- Be fully informed in advance of receiving services, as well as any modifications to the plan of care, and of your rights and responsibilities.
- Be informed in advance about the care/services provided and your financial responsibility.
- Be informed about the scope of services provided by Premier Pharmacy Services, specific limitations on those services, and assistance with any transfer of appropriate care or service to another organization.
- Participate in the development and periodic revision of the plan of care.
- Make decisions to accept, refuse or withdraw medical care after the consequences of refusing care or treatment are fully presented.
- Be informed of patient rights under the state law to formulate an Advance Directive, if applicable.
- Be treated with respect, compassion, consideration, and recognition of patient dignity and individuality individual. Your care will include consideration of the psycho-social spiritual cultural and economic variables that influence your perception of illness.
- Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown sources, and misappropriation of patient property.
- Voice grievance/complaints regarding treatment or lack thereof, or recommended changes in policy, personnel, or care/services without restraint, interference, coercion, discrimination, or reprisal.
- Have grievance/complaint regarding treatment or care that is (or fails to be) furnished or lack of respect of property investigated.
- Receive a response to a written complaint concerning services rendered upon request and in a timely manner.
- Confidentiality and privacy of all information contained in the patient record and of Protected Health Information (PHI).
- Be advised on Premier Pharmacy Services’ procedures regarding the disclosure of clinical records.
- Choose a healthcare provider, including a physician or other licensed practitioner with prescribing authority.
- Receive appropriate care without discrimination in accordance with prescriber’s orders, if applicable.
- Be informed of any financial benefit to Premier Pharmacy Services if services are transferred to another party.
- Receive communication regarding our care in a language or form that is readily understood by you, either by an interpreter or in writing.
- Have personal health information shared with the program offered by Premier Pharmacy Services only in accordance with state and federal law.
- Identify staff members, including their job title, and speak with a staff member’s supervisor if requested
- Speak to a health professional.
- To receive information regarding the patient management program.
- Decline participation or opt-out of the patient management program at any point in time by calling 800-540-4700 or emailing info@premierpharmacy.com.
- Have your family (including significant other) and/or surrogate decision-maker participate in the facilitation of your care and exercise your rights if you are unable to do so
- Receive prompt and appropriate treatment for which you are eligible.
- Express your concerns regarding the timeliness of services and devices rendered.
- Discuss your eligibility and entitlement for programs and services with a staff member.
- Be given the opportunity to address issues with a staff member.
- Be involved, in discussions and resolutions of any conflicts or ethical issues related to your care.
- Be informed of any experimental or investigational studies which involve your care, and maintain the right to refuse any participation in these activities.
- Receive consultation. The pharmacist is available at 626-626-9400 or 800-540-4700
- Be assisted with the best medical capabilities available to date in order to assist with any pain which you might experience.
- Request and receive any records with Premier Pharmacy for me to examine.
- Be informed and supplied all documented consent forms, if you agree to participate in any educational classes which are filmed or recorded within our organization.
- Be fully informed of one’s responsibilities.
- To treat the staff with the same respect and courtesy, you wish to be treated with.
- To submit any forms that are necessary to receive services and participate in the Patient Management Program.
- To give accurate clinical and contact information, and notify the patient management program of any changes in this information.
- Of your actions, if you refuse treatment or do not follow prescriber or pharmacist’s instructions.
- To notify your physician when you are feeling ill or encounter any unusual physical, mental stress, or sensations.
- To notify Premier Pharmacy Services if you will not be home for scheduled delivery or pick up.
- To notify Premier Pharmacy Services prior to changing your place of residence or your telephone number.
- To notify Premier Pharmacy Services if you become hospitalized.
- To inform one of our staff members of your health history, including past hospitalizations, illnesses, injuries, etc.
- To provide accurate information concerning your present health, medication, allergies.
- To help assist in developing and maintaining a safe environment as well as participating in the development/update of home care plan of service/treatment.
- To notify Premier Pharmacy of any additional information concerning issues that you do not understand.
- To notify Premier Pharmacy Services of any concerns about the care or services provided.
- To notify Premier Pharmacy immediately if you acquire any infectious disease during the time you are receiving services and/or care from us. (Except where exempted by law)
- To remove refrigerated items and let stand at room temperature one hour prior to use or as instructed by Nurse or Pharmacist.
- To inspect medication for leaks, change in color, or presence of particles prior to each administration.
- Notify your treating provider of your participation in the patient management program.
- To call our pharmacy if:
- You accidentally waste or miss a dose of your medication
- You find any damaged supplies
- Administration of the first-lifetime dose of a new medication should be discussed with our pharmacist and/or nurse.