Home Delivery Agreement

Home Delivery Agreement

Dartmouth-Hitchcock Pharmacy

Home Delivery

1000 Quality Drive

Hooksett, NH 03106

Toll Free Phone: (855) 280-3893

Fax: (855) 302-4715

Dartmouth-Health.org

I authorize Dartmouth-Hitchcock Pharmacy to:

• Mail using the credit card, courier, and address on file for me and my enrolled family members

I understand Dartmouth-Hitchcock Pharmacy will not:

• Contact me for copays totaling less than $300.00 (except for specialty medications)

I understand:

• The risks of having medications sent by mail. The pharmacy will work with me and my insurance plan to replace damaged

or lost medications

• I must inform the pharmacy of any changes to my credit card or address or request a shipment be held for pick up before it

is sent to me

• The pharmacy may change the courier to prevent delays in delivery due to weather or courier closures

• The pharmacy will email the tracking information to my provided email address

• The pharmacy will text important order updates to the provided cell phone number (message and data rates apply)

• If I use multiple addresses, I will call the pharmacy with the correct address when refilling. If not, each order will be shipped

to the primary mailing address

• The pharmacy will attempt to alert me of a new medication. If we cannot get in touch with you, the order will be placed on hold

Opt in

I want prescriptions automatically refilled. The pharmacy cannot offer this for specialty prescriptions, medications taken on an as needed basis, controlled medications, or medications paid for by Medicare or VT Medicaid.

Name*

DOB*

Cell

Additional Enrollee 1

DOB Additional Enrollee 1

Cell Additional Enrollee 1

Email Additional Enrollee 1

Additional Enrollee 2

DOB Additional Enrollee 2

Cell Additional Enrollee 2

Email Additional Enrollee 2

Additional Enrollee 3

DOB Additional Enrollee 3

Cell Additional Enrollee 3

Email Additional Enrollee 3

Primary Mailing Address*

Secondary Address (Optional)

Please call the pharmacy at 603-653-3785 to add a credit card on file

Shipment Carrier

*Refrigerated items will ship UPS Next-Day Air or FedEx Overnight to a physical address

FedEx

Surepost

UPS

Delivery Instructions

ie. Leave on porch, deliver to back door etc.

Note: this is dependent on the carrier, but we will do our best to fulfill requests

I do not allow the carrier to be changed

Filled out by:

Date:

Send me a copy of my responses

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