WellPack Patient Intake

Choose Role

Demo role screen. Real version will use individual logins and audit logs.

New Patient Packet

Demo only. Do not enter real patient information yet.

Live PDF creation, Google Drive storage, and Slack notification will connect in the next backend step.

Patient First Name Patient Last Name Date of Birth Cell Phone Address Allergies Current Pharmacy Current Pharmacy Phone Pharmacy Contacted? Current PCP PCP Phone Number Transfer Notes

Patient IDTap to upload or take photo Insurance FrontTap to upload or take photo ExtraTap to upload or take photo

Patient Signature

Patient Consent Review

This form authorizes WellPack Pharmacy to provide pharmacy services, coordinate prescription care, communicate with you and your healthcare providers, and submit claims to your health insurance plan or other applicable payer. Please review this form carefully. By signing below, you acknowledge that you have read and understood it, have had an opportunity to ask questions, and voluntarily provide the authorizations described.

1. Authorization to Bill Insurance

I authorize WellPack Pharmacy to submit claims and related information on my behalf to Medicare, Medicaid, Medicare supplemental insurance, commercial insurance plans, pharmacy benefit managers, or other applicable third-party payers for medications and pharmacy services furnished to me. I authorize payment of applicable pharmacy benefits directly to WellPack Pharmacy when permitted by my plan.

I understand that I am responsible for applicable copayments, coinsurance, deductibles, non-covered services, and other patient financial responsibility determined by my insurance plan, except where payment is adjusted or waived as permitted by applicable law or an authorized assistance program.

2. Voluntary Choice of Pharmacy

I voluntarily choose WellPack Pharmacy as my pharmacy provider. I understand that I may choose another pharmacy at any time, subject to applicable insurance-network requirements, prescription-transfer requirements, and federal or state law.

I acknowledge that I have not been offered or provided cash, gift cards, gifts, rewards, or other improper remuneration in exchange for selecting WellPack Pharmacy or transferring my prescriptions to WellPack Pharmacy.

3. Prescription Transfer & Care Coordination

I authorize WellPack Pharmacy, when permitted by law, to contact my current or previous pharmacy, prescribing healthcare providers, caregivers, insurance plans, pharmacy benefit managers, and other appropriate parties for purposes related to my pharmacy care, including transferring eligible prescriptions; requesting refills or renewals; clarifying prescription directions or medication-related questions; verifying prescription benefits, coverage, eligibility, and reimbursement information; and coordinating services reasonably necessary to dispense and manage my prescriptions.

I understand that certain prescriptions may not be transferable under applicable law and may require a new prescription from my healthcare provider.

4. Refill & Prescription Communication

I authorize WellPack Pharmacy to contact me regarding prescription status, refill reminders, insurance or coverage issues, prior authorization status, medication pickup or delivery coordination, requests for updated information, and other communications reasonably related to my pharmacy care, using the contact information I provide and subject to applicable law and my communication preferences.

5. Acknowledgment

I understand that signing this form does not guarantee insurance coverage for any medication or service. Coverage and financial responsibility are determined by my health plan. I certify that the information I provide is accurate to the best of my knowledge and acknowledge receipt of, or access to, applicable WellPack Pharmacy patient information and policies.

Patient confirms consent and pharmacy change request information is accurate.