CONFIRMATION AND REPRESENTATIONS
I enter into this agreement with CRX International Inc. (“CRX”) so that I
may obtain access to medically-necessary and lawfully prescribed drugs at low
costs. I represent:
- I am of the age of majority in the jurisdiction in which
I ordinarily reside.
- I am not restricted from making my own medical decisions
under the laws of the jurisdiction in which I ordinarily reside.
- I certify that I am a resident of the United States and
not a resident of any other country.
- I am under the care of a duly qualified and licensed
physician in the United States (my “U.S. physician”) and the medicine that I
ask CRX to assist me in obtaining was prescribed for me by my U.S.
- My U.S. physician has examined me within the last 12
months and will examine me at least once every 12 months while I am taking
- Any medicine that I ask CRX to assist me in obtaining
is medicine that I have already taken, under my U.S. physician’s orders and
supervision, for at least 30 days prior to placing an order for the medicine
- My care by my U.S. physician is ongoing and I do not seek
and will not rely on any medical information from CRX or any CRX
- I have not violated any laws in the jurisdiction in which
I ordinarily reside (or, if different, in the jurisdiction in which the
prescription was issued) in obtaining the prescription for the ordered
- The prescription issued by my U.S. physician has not been
altered in any way nor has it been filled previously.
- I will use any medications obtained for me through CRX
strictly in accordance with the instructions provided by my U.S. physician.
- The medicine dispensed in accordance with my prescription
will not be used in any way whatsoever except as directed by my U.S.
- I will not permit anyone else to use the prescription or
any medications which I receive.
- In the event that I suffer any side effects from any
medication obtained for me by CRX, I will immediately contact my U.S.
- All information that I give to CRX is true.
AUTHORIZATION AND CONSENT
I consent to, and authorize, the following:
- I hereby appoint CRX and its delegates and contractors
(collectively referred to as “CRX”) as my paid agents and
attorneys-in-fact for the purposes of obtaining prescriptions which
correspond to the prescriptions issued by my U.S. physician and of arranging
for pharmacies to dispense to me medications as prescribed.
- CRX may perform any act that I could myself perform in
having my prescription reviewed by any physician, pharmacist, or pharmacy
technician and in having the prescribed medication dispensed by a pharmacy
and delivered to me.
- CRX may arrange the purchase and delivery of the
medications prescribed to me, on the terms set forth in this agreement, as
if I personally took such actions.
- CRX may receive and collect any and all information
about me and my health, including but not limited to my full name, address,
telephone number, e-mail address, personal medical information, and payment
information, and may maintain such information on file as necessary to
verify and process future orders and to obtain payment and reimbursement for
them. CRX and CRX contracted physicians and pharmacists may share any
and all information received from or about me with my U.S. physician, CRX
contracted physicians and pharmacists, and my benefits plan administrator,
and their respective assistants and agents, for the purposes of obtaining
medicine as prescribed for me and of obtaining proper payments for the
medicine and related services.
- I authorize and instruct my U.S. physician to release to
CRX (and any CRX contracted physician, pharmacist, and pharmacy
technician) any and all personal medical information pertaining to me
(“Personal Medical History”), including but not limited to all medical
records, medical reports, progress notes, nurses’ notes, reports on
diagnostic tests, medical opinions, X-ray records, imaging records,
laboratory reports, and/or any other knowledge or information which my U.S.
physician may possess.
- I agree to instruct my U.S. physician to issue my
prescription on paper (if necessary for dispensing by a pharmacy located
outside my U.S. physician’s jurisdiction) and to send (by mail, by fax, via
the internet or otherwise) to CRX from my U.S. physician’s office the
original signed copy of the prescription.
- CRX and its contracted physicians, pharmacists, and
pharmacy technicians may contact my U.S. physician to discuss my
prescription if necessary.
- CRX contracted physicians may issue prescriptions for
medications I have ordered if they deem it advisable and appropriate.
- CRX may make payments on my behalf to CRX
contracted pharmacies for dispensing medicine in accordance with my
prescriptions and to CRX contracted physicians for services rendered on
- I request and authorize my plan payor, as my appointed
agent, to pay for all products and services relating to the prescription
medicine that I obtain through CRX in such amounts as are found
appropriate by plan payor in accordance with the benefits plan.
ACKNOWLEDGEMENT AND RELEASE
I hereby make the following acknowledgments and releases to CRX and all
its employees, delegates, agents, and contractors, including physicians,
pharmacists, pharmacy technicians, nurses, receptionists and staff:
- My U.S. physician is my primary physician. Any CRX
contracted physician is being asked to review the information contained in
my Personal Medical History only for the purpose of authorizing the medicine
prescribed for me by my U.S. physician to be dispensed to me by a CRX
- CRX has made no representations or warranties to me,
including, without limitation, representations or warranties regarding the
use of fitness for any particular purpose of the medications delivered
(including, without limitation, its appropriateness for curing or helping
relieve any particular ailment, illness or disease, or its potential or
actual side or adverse effects whether previously known or unknown).
- I wish to obtain a prescription from a CRX contracted
physician and have enlisted the services of CRX to facilitate it. I
understand that the CRX contracted physician will rely on the accuracy of
the examination performed, and the prescription provided, by my U.S.
- I am aware that CRX may transmit my personal
information by electronic means (for example fax, or via the internet) to
its agents, contracted physicians and pharmacies. I understand that the use
of electronic means will enhance the efficiency and timeliness of processing
my order. I also understand that CRX, as a custodian of my personal
information, will take all appropriate precautions to protect my personal
information from improper disclosure or use. I hereby consent to CRX’s
transmission of my personal information by electronic means to its
delegates, employees, contracted physicians and pharmacies.
- I release CRX and all of its officers and directors,
agents, delegates, employees and contractors from any and all liability,
claims, and causes of action with respect to errors or omissions by the
company or agency responsible for transporting my order.
- I acknowledge that I have purchased my medications
internationally for personal use and I specifically confirm, acknowledge and
agree that title to my medications passes to me when my medications are
shipped from the CRX contracted pharmacy.
FURTHER ACKNOWLEDGEMENT & RELEASE
I hereby make the following further acknowledgement and release the plan
holder, its employees, officers, agents, heirs and assigns:
- I acknowledge that the plan holder has made no
representations or warranties to me, including without limitation,
representations or warranties regarding the use for any particular purpose
the medication(s) delivered, including without limitation, its
appropriateness for curing or helping relieve any particular ailment,
illness or disease or its potential or actual side or adverse effects
whether previously known or unknown.
- I acknowledge that child protective packaging may not be
used in filling my prescription. I promise that upon my receipt of the
medicine I will take all steps necessary to prevent any child from having
unauthorized access to the medicine. I hereby release CRX and all its
officers, directors, agents, delegates, employees, and contractors,
including the pharmacy that fills my prescription, from any and all claims
arising from or relating to the use of, or failure to use, child protective
- I release the plan holder its officers, employees,
agents, heirs and assigns from (i) any and all causes of actions with
respect to errors or omissions by the company or agency responsible for
transporting my order; (ii) any and all causes of actions with respect to
errors or omissions by CRX in obtaining the prescription medications to
fill my order; (iii) any and all causes of actions regarding the use for any
purpose whatsoever of any medications delivered through this program.