PD Rx - AT HOME PHARMACY NOTICE TO PATIENTS

This notice is intended to help you make a fully informed decision about your rights to obtain your prescription medications from a pharmacy of your choosing. This is further intended to disclose to you that Pain Clinic Associates, PLLC regularly purchases the right to bill your insurer for certain medications filled by Patient Direct RX, LLC ("PD Rx"), a mail order pharmacy. If you decide to obtain your prescription medications from PD Rx, Pain Clinic Associates, PLLC's right to bill would allow Pain Clinic Associates, PLLC to bill and receive payment from your insurer.

Please be aware that you are free to select any pharmacy of your choosing. You are not obligated to use the services of Patient Direct Rx. Pain Clinic Associates assures you that you would not be treated differently if you do not choose to obtain pharmacy drugs from PD Rx.

Signature
If minor
SIGNATURE DELIVERY WAIVER

By my signature, I am authorizing and requesting PD Rx to allow the shipping carrier to leave any prescriptions at the following address:

Signature

I understand that any controlled medications will not be replaced, and I release PD Rx, Pain Clinic Associates, PLLC and the shipping carrier from all liability for any loss or damage that may result from leaving this shipment at my request.

If minor
submitting