New Patient Enrolment Form
Patient Advocate Help
Patient Welcome Packet
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 insure 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 writing, in advance of receiving services, of your rights and responsibilities.
- Be treated with dignity as an individual, with compassion and respect. Your care will include consideration of the psycho-social spiritual cultural and economic variables that influence your perception of illness.
- 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.
- 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.
- Identify pharmacy personnel and their job title, and to speak with a supervisor of the pharmacy personnel if requested.
- Receive a response to a written complaint concerning services rendered upon request and in a timely manner
- Make decisions to accept, refuse or withdraw medical care.
- Decline participation or opt-out of the patient management program at any point in time
- Be informed if prescription care or services are not within our scope of service, and assist with any transfer of appropriate care or service organization.
- Be informed of any financial benefit to Premier Pharmacy Services if services are transferred to another party.
- Select those who provide your services.
- Be involved, in discussions and resolutions of any conflicts or ethical issues related to your care.
- To receive information regarding the patient management program.
- 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
- Speak to a health professional
- 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.
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 participate in the Patient Management Program.
- To give accurate clinical and contact information, and notify the patient management program of any changes in
- 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 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
- 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
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.
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.
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.
Should it become necessary to give access to your PHI to an outside party performing services on our behalf, we will require the party to have a signed agreement with us to ensure the same degree of privacy protection to your information is extended by the other party as we do. The privacy law permits us to make some uses or disclosures of your PHI without your consent or authorization. The following describes each of the different ways that way may use or disclose your PHI:
- Uses and Disclosures to Treatment: We may disclose your PHI to those who are involved in providing medical and/or nursing care services and treatments to you. We may also disclose your PHI to outside entities performing other services relating to your treatment.
- Use and Disclosures Related to Payment: We may use or disclose your PHI to bill and collect payment for items or services we provide to you.
- Use and Disclosures Related to Health Care Services: We may use or disclose your PHI to perform certain functions in monitoring and improving the quality of care and services that you and others receive. We may also disclose your PHI for auditing, care planning, quality improvement, and learning purposes.
- Use and Disclosures Related to Treatment Alternatives, Health Related Benefits and Services: We may disclose your PHI to contact you to inform you of treatment alternatives or health related benefits and services that may be of interest to you, such as newly released medication that has a direct relationship to your treatment or medical condition.
For uses and disclosures of your PHI beyond the above expected purposes, 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’re 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. These uses or disclosures that we may make without your consent include the following:
- When required by law
- Abuse, neglect, or domestic violence
- Communicable disease
- Disaster relief
- Food and Drug Administration (FDA)
- For public health activities
- For health oversight activities
- To coroners, medical examiners, funeral directors, organ procurement organizations or tissue banks
- For research purposes
- To avert a serious threat to health or safety
- For judicial or administrative proceedings
- To law enforcement
- To personal representatives
- For specific government functions
- For workers compensation
Your Rights Regarding your Protected Health Information
- The Right to Request Restrictions on Uses and Disclosures of Your Protected Health Information: 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.
- The 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.
- The Right to Amend or Correct Your Protected Health Information: 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.
- The 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 it is reasonable for us to do so.
- 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.
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.