Parent / Guardian Information


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Payment Section
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Please provide credit card details for billing registration fee

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(Credit Card will be charged after filling Prescription.)



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I acknowledge and assume responsibility and grant authorization for LTC SCRIPTS and/or its parent company or affiliates to charge the above credit card for registration and sign-up fees where applicable. I also acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication that LTC SCRIPTS cannot get reimbursement for, as well as any co-insurance and deductibles and charges for OTC/Sundries which I agree will be billed to my credit card by LTC SCRIPTS. I authorize LTC SCRIPTS to contact my insurance company for verification of coverage, billing, and collections for my medications. As per our HIPAA agreement, all personal information received will be solely maintained for the purposes of dispensing prescriptions and insurance collection.


I acknowledge that I have read and understand the following.


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