Patient Attestation

Please complete this form to confirm that you requested, received, and paid your full copayment responsibility for prescription medication(s) dispensed by Charleston Care Pharmacy.

Your information is secure Your information will only be used to verify the attestation and prescription record.

Patient Information

Fields marked with an asterisk are required.

First Name *

Last Name *

Date of Birth *

Phone Number *

Street Address (Optional)

City (Optional)

State (Optional)

ZIP Code (Optional)

Email Address (Optional)

Patient Confirmation

Please check all four statements.

I received my prescription(s) from Charleston Care Pharmacy.

I paid my full copayment responsibility.

I requested Charleston Care Pharmacy to fill my prescription(s).

A valid prescriber-patient relationship exists.

I certify the foregoing is true. I am aware that willfully false statements may be subject to punishment.

Patient Signature

Sign inside the box below.

Patient Signature *

Date Signed *

Prescription Information

This section will be completed by Charleston Care Pharmacy after verification.

Rx #	Date of Service	Medication	Quantity
To be completed by Charleston Care Pharmacy after verification.

You do not need your prescription number.
Charleston Care Pharmacy will locate the correct prescription using your name, date of birth, phone number, and any address information provided.