Please fill out both pages of thisform and fax them to (449-4531) or bring them to the pharmacy (1st Floor, Creighton University Medical Center—West Entrance)

Creighton Clinic Pharmacy

Prescription Delivery and Waiver Form

Please complete the entire form:

Name: ______

Home Address: ______

Campus Address (for Delivery): ______

Campus Phone Number: ______

Birth date: ______

Prescription Insurance Information:

_____Creighton’s Health Insurance

Member ID Number (SSN) ______

_____ Other Health Insurance

Please fax us a copy of your card.

_____New Prescriptions

_____Will Fax

_____Attached

_____Will bring new prescriptions to the pharmacy

_____Other

_____Transferring prescription(s) - Please Print

Name, location, and phone number of your current pharmacy

______

______

Names and/or prescription numbers of the prescriptions that you would like to transfer to the Creighton Clinic Pharmacy:

______

______

______

______

Creighton Clinic Pharmacy

Phone – 402.449.4560 Fax – 402.449.4531

Please complete this page for each family member receiving deliveries from this pharmacy.

Creighton Clinic Pharmacy

Delivery Authorization and Waiver

Patient/Insured. The patient/insured whose prescriptions may be delivered is:

Name D.O.B.______

CU Employee receiving delivery (If other than above)______

CUWorksiteAddress

CU Phone #

I authorize Creighton Clinic Pharmacy (the Pharmacy) to deliver my prescriptions, including refills, to the above-listed Creighton University (CU) worksite address. I further authorize the Pharmacy to leave my prescriptions with CU staff in the department/work area.

I understand that:

  • I will be required to arrange for payment of all co-payments/medication expense prior to delivery of my prescriptions. Payment may be made via credit card, Payflex, money order or personal check. My prescriptions will be returned to the Pharmacy for pick-up if payment is not received prior to, or at the time of delivery.
  • My prescriptions will be packaged and will not externally identify the contents as containing prescription medications or my health information.
  • Packages shall be marked “CONFIDENTIAL”.
  • The Pharmacy will only deliver prescriptions to the worksite address above during normal working hours, Monday through Friday, 8:30 a.m. to 4:30 p.m., excluding University holidays
  • If my prescription is ordered on a weekday other than Friday, I will allow 24-48 hours from the time the request is received in the Pharmacy for delivery of routine prescriptions; I understand special order items, transfers from other pharmacies, prescriptions ordered on Friday or a weekend, or prescriptions with no refills remaining will take additional time to be delivered.
  • I release, waive, discharge and covenant not to sue CU, the Pharmacy and CUMC from and for any liability, claims, demands, actions or causes of action whatsoever arising out of any loss, damage or injury that may be sustained by me or my property as a result of the delivery of my prescriptions including, but not limited to, theft or loss of my prescriptions by any third party (including CU staff) or breach of privacy ifCU staff open and/or review the contents of packages from the Pharmacy.
  • It is my duty to notifythe Pharmacy in writing as soon as possible of any changes in my work status (or that of the employee named above) at CU, including relocation of office/work area or termination of employment at CU.
  • I may revoke this authorization and waiver at any time by written notice to the Pharmacy.
  • This authorization and waiver terminates when the worksite address specified above changes. In order to renew it, I must complete new forms and submit to the Pharmacy.

I ACKNOWLEDGE RECEIPT OF Creighton University’s Notice of Privacy Practices.

Patient’s SignatureDate

______