Receipt of Medication Confirmation

Thank you for choosing Volunteer Pharmacy for your prescription needs. If requested by our staff, please fill out the following form to confirm you have received your prescription order.

Thank you for allowing our pharmacy to serve you, it is truly our pleasure.

If you wish to CONSULT with our PHARMACIST, please call on any medications anytime at 800-690-8980.
You may submit this form to confirm receipt of your prescription. This must be done with every refill as well for insurance purposes. Your insurance company may refuse payment unless you sign and return this form at your earliest convenience.

Your signature on this form certifies you received a service or item dispensed on the date(s) listed and that the information contained hereon is correct and that the person for whom the prescription was written is eligible for the benefits. You also certify that you have received the medication identified below and authorize release of all the information contained on this log and prescription to which it corresponds, to the plan administrator, the underwriter, the sponsor, the policyholder, the Workman’s Compensation Commission (if applicable), and the employer. You hereby assign to this provider pharmacy any payment due pursuant to this transaction and authorize payment directly to this provider pharmacy. In addition: You understand that if payment for this service or item will be from Federal and State funds and that any false claims, statements or documents, or concealment of material facts may be prosecuted under applicable Federal and State Laws. Furthermore, as required by State Laws you acknowledge receipt of an OFFER TO COUNSEL and have accepted or refused counseling as indicated. WORKERS COMPENSATION ONLY: Your signature on the reverse side of this card certifies that this medication is for the treatment of an on-the-job injury. ALL OTHER THIRD PARTY PROGRAMS: Your signature on this form certifies that this medication is not for treatment of an on-the-job injury.