Welcome to P4 Pharmacy

As a new member to the pharmacy, we would like to let you know that we strive to keep costs as affordable as we can! **Note if you have Medicare A/B this insurance only covers hospitals and doctor office visits. A Medicare Part D plan is required if you want to use insurance to help cover the costs of the medications. **If you have Utah State Medicaid, please note that not everything will be covered by Medicaid, such as over the counter medications and medications that do meet eligibility requirements. We will do the best we can to keep the over-the-counter medications (OTC) at an affordable price. Thank you for this opportunity! Please enter your information below. Information is encrypted once you push "Submit"

Welcome to P4 Pharmacy

As a new member to the pharmacy, we would like to let you know that we strive to keep costs as affordable as we can! Note if you have Medicare A/B this insurance only covers hospitals and doctor office visits. A Medicare Part D plan is required if you want to use insurance to help cover the costs of the medications. If you have Utah State Medicaid, please note that not everything will be covered by Medicaid, such as over the counter medications and medications that do meet eligibility requirements. We will do the best we can to keep the over-the-counter medications (OTC) at an affordable price. Thank you for this opportunity! Please enter your information below. Information is encrypted once you push "Submit"

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All sections in RED are required to be filled out before submitting

Resident/Patient Information

First Name

Last Name

Date of Birth (ex: MM/DD/YYYY)

SSN #

Any Known Drug Allergies

Community Name or Residence Address

Room #

Move In Date

Front of Pharmacy Insurance Card

Upload File

Primary Care Physician

Back of Pharmacy Insurance Card

Upload File

Insurance Card ID #

RX Bin #

RX PCN #

Previously used pharmacy phone number

Medicaid Number if applicable

Is this patient on Hospice? If so, what is the name of the Hospice Agency?

Responsible Party (Payee or POA)

You may use our Payment Portal once you have received your first invoice in the mail!

We work hard to take care of your needs, even your financial needs. Please call ASAP if you need accommodations or special billing arrangements. Our billing department can be reached at 385-415-5863 Ext. 2. Invoices are mailed between the 2nd & 5th of each month.

This serves as a resident responsible party agreement, ensuring clear communication and accountability for copays and out of pocket expenses

First Name

Last Name

Mailing Street Address (mail invoices to)

City

State

Zip Code

Phone Number

Email

Emergency Contact

If you do not have a Responsible Party or POA, you will be required to put an Emergency contact in order to submit this form.

First Name

Last Name

Phone Number

Payment Agreement - please read and sign to show your agreement

Payment Agreement

Your Signature

Select a date

Notice of Privacy - please read and acknowledge with your signature

Notice of Privacy Practices

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