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Guardian Pharmacy of Maine
Long-Term Care Pharmacy Services
About Us
Our Story
Core Values
Our Team
Areas Served
Careers
Services
Our Services
Assisted Living & Memory Care
Skilled Nursing
Behavioral Health
Intellectual & Developmental Disabilities
Hospice Care
Outpatient Services
Other Services
GuardianShield
News & Events
News & Events
Media Contact
Contact Us
Providers
Provider Services
GuardianHub Login
Admission Checklist
Vaccine Consent Form
Documents & Forms
GuardianLink
Helpful Links
Residents
Resident Services
Make A Payment
Documents & Forms
Helpful Links
Bill Pay
Home
About Us
Our Story
Core Values
Our Team
Areas Served
Careers
Services
Our Services
Assisted Living & Memory Care
Skilled Nursing
Behavioral Health
Intellectual & Developmental Disabilities
Hospice Care
Outpatient Services
Other Services
GuardianShield
News & Events
News & Events
Media Contact
Providers
Provider Services
GuardianHub Login
Admission Checklist
Vaccine Consent Form
Documents & Forms
GuardianLink
Helpful Links
Residents & Families
Resident & Family Services
Make a Payment
Documents & Forms
Helpful Links
Contact Us
Admission Checklist
"
*
" indicates required fields
Facility name
*
Name of facility staff completing admission
*
First
Last
Email
*
Phone
*
Admission Type: *
Admission Type:
*
New Admission
Re-Admission
Patient Demographics:
Patient Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
*
Medicare Number
*
Primary Physician
*
Drug Allergies
*
POA Name
*
First
Last
Phone - POA
*
Mailing Address - POA
*
Email - POA
*
Insurance Information:
ID#
*
RX BIN#
*
PCN#
*
Rx Group#
*
Note: Failure to provide this information will result in medications to be billed to the facility until completed information is received.
Secondary Insurance (if applicable):
Provider Name
ID#
RX BIN#
PCN#
Select from below:
*
Verified signed orders by Prescriber or Telephone Order Documentation (MD/RN)
Order duration indicated (ALF/Group Home/Res Care only)
Valid prescriptions for controlled substances (CII-CV)
Level of Care is specified (SNF/NF if applicable)
SNF Level of Care
If SNF Level of Care please include Discharge Summary for Pharmacist to perform Initial Medication Reconciliation and Initial Review (required by regulation)
If SNF Level of Care please indicate Payor Source:
Payor Source
Medicare
Mainecare
Private Pay
Other
Medications Needed: *
Medications Needed
*
All
All RX / No OTC
Profile ONLY
Specific Med(s) list below
Specific Medications:
Any IV's or Compound Medications?
*
Yes
No
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