Form Ph03 PDF Details

Navigating healthcare needs efficiently is vital in today's fast-paced world, and pharmacies play a crucial role in this landscape. The Costco Pharmacy Confidential Patient Information Form, commonly known as Form #PH03, is a cornerstone for initiating a streamlined and personalized pharmacy service experience. This comprehensive form serves multiple purposes, from confirming a patient's prescription insurance coverage to understanding their medical history for optimal care. Patients are first asked about their insurance coverage, including specific inquiries about Medicare Parts D and B, to tailor their benefits accurately. Furthermore, the form delves into personal details such as name, contact information, and residence, ensuring that communication and medication delivery can be conducted without a hitch. It shifts focus to health specifics, asking patients to disclose any chronic medical conditions they might have, which helps in predicting and preventing potential drug interactions and adverse effects. Allergies to medications are another critical area covered, safeguarding patients from harmful reactions. Additionally, the form inquires about the use of safety caps and lists medication currently being taken, which encapsulates the patient's health profile, enabling pharmacists to provide a safe, effective, and personalized service. At its core, the Ph03 form reflects Costco Pharmacy's commitment to member health, safety, and satisfaction while emphasizing the significance of accurate patient information in delivering quality pharmacy care.

QuestionAnswer
Form NameForm Ph03
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesNSAIDS, costco pharmacy fax forms, Cephalosporins, Sulfonamide

Form Preview Example

COSTCO PHARMACY - CONFIDENTIAL PATIENT INFORMATION FORM

Do you have insurance coverage for prescriptions? If not, ask us about the Costco Member Prescription Program!

You can start saving today with our FREE discount program, available to our members without insurance!

Name _________________________________________________________________________________

 

Last

First

Middle Initial

House Address (No PO Box) _______________________________________________________________

City ________________________________________________ State ____________ Zip ______________

Home Phone

(_______) _______-__________ Birth Date _____/_____/________ Sex

□ Male □ Female

Cell Phone

(_______) _______-_______ E-Mail______________________________

Safety Caps Y____N____

INSURANCE COVERAGE INFORMATION

 

 

 

Do you have insurance coverage? (Y)___ (N) ___ (Please present card)

 

Do you have Medicare Part D? (Y)___ (N) ___

Do you have Medicare Part B? (Y) ___ (N) ___

Do you have Medicare Advantage? (Y) __ (N)___

If Part B, do your have supplemental Rx coverage (Y) __ (N) ___

 

 

If Part B, Is beneficiary in a skilled nursing home? (Y )__(N ) ___

CHRONIC MEDICAL CONDITIONS

 

 

 

□ Diabetes I (Insulin) 250.01

□ Diabetes II (Non-Ins.) 250.02

□ Hypo-Thyroid 243.0

□ GERD 530.1

□ High Cholesterol 272

□ High Blood Pressure 401

□ Epilepsy 345.11

□ Migraine 346

□ Depression 311

□ ADD/ADHD 314.0

 

□ Insomnia 307.41

□ Anxiety 300.0

□ Osteoporosis 733.0

□ Arthritis 714

 

□ Glaucoma 365

□ Angina 413.0

□ Asthma 493

□ Other(s) _________________________________________________________

ALLERGIES TO MEDICATIONS

□Penicillin 000476 □ Cephalosporins 000477 □ Sulfonamide 000491 □ Erythromycin 000479 □ Quinolones 003668

□ Aspirin 000270 □ Acetaminophen 900013 □ NSAIDS 000439 □ Codeine 000268 □ Morphine 000268 □ Antihistamines 000797, 000798, 000799, 000801, 000800 □ Other __________________ □ No Known Allergies 900388

What other medications are you taking?____________________________________________________________

Patient Signature______________________________________________________________________________Date________________________________

Form #PH03 6.6.11

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Completing part 1 in Antihistamines

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Completing part 2 in Antihistamines

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