Diamond At Home Enrollment

Facility Name

Resident Name

Email

Date of Birth

Discharge Date

(Please request at least 2-3 days prior to discharging home)

I request a 30-day supply of medications to take home on discharge and I understand some medications may be limited to a 14-day supply per insurance requirements. I would also like a consultation of my medication regimen with a pharmacist via a phone call after my discharge (This consultation will review your current medication orders to confirm any medication changes and address any questions or concerns).

I would like a copy of Diamond’s Notice of Privacy Practices

By signing below, I understand I will be responsible for any medications not covered by my insurance company and can be paid by check or with credit card. I certify that I want to receive Diamond At Home discharge services on medications that my provider is prescribing. I authorize payment for the prescriptions directly to Diamond Pharmacy Services and acknowledge that any false claims or documents may be prosecuted by law. All information provided on this form is correct to the best of my knowledge.

For Medicare Residents: if you disagree with the information given to you by the pharmacy you have the right to file a complaint.

Resident/Responsible Party Signature

Date