Terms & Conditions
SERVICE: Lone Star Script Care LLC (LSSC) is a fee-based medication advocacy service that assists patients in enrolling in applicable pharmaceutical companies' patient assistance programs. THIS IS NOT INSURANCE AND IS NOT CONNECTED TO ANY INSURANCE PRODUCT OR INSURANCE COMPANY. The medications themselves are offered by the pharmaceutical companies through their patient assistance programs at no cost to the eligible applicant. I also understand and acknowledge that it is each individual pharmaceutical company who makes the final decision as to whether I qualify for their assistance program(s). I understand that (LSSC) reserves the right at any time, and without notice, to modify the application form, to modify or discontinue this or any program: and to terminate assistance. I understand that completing this enrollment does not ensure that I will qualify for this program.
The medication is shipped directly from the pharmaceutical companies and delivered either to your home or physician's office, depending upon the manufacturer delivery guidelines. I also understand LSSC reserves the right to rescind, revoke, or amend its services at any time. LSSC does not guarantee your approval for patient assistance programs; it is up to each applicable drug manufacturer to make the eligibility determination. Each drug manufacturer independently sets its own eligibility criteria and determines which products are included in their assistance programs. Medications covered are subject to change at any time. LSSC assembles and submits your application to the pharmaceutical company but does not participate in the review process to determine which applicants are eligible. The role of LSSC, its affiliated companies, and its subcontractors shall be limited to administrative functions, including data entry and verifying the accuracy and completion of eligibility and enrollment information contained in this application form. With respect to my applications, I understand that my physician and the dispensing pharmacy will be responsible for the information contained in this application form. I authorize LSSC to forward my applications to various assistance programs on my behalf. LSSC is not acting as a dispensing pharmacy. LSSC is not responsible for checking or verifying any information contained in this application, including but not limited to, allergies, medical conditions or other medications being taken by the patient. LSSC will use all reasonable commercial efforts to enroll the client in the various PAP's offered by the pharmaceutical companies for the medications prescribed by the client's physician.
FEES: Prescription Assistance Programs (PAPS) can modify or discontinue programs without notice. PAP's are available to all qualified individuals FREE of charge, and I am solely responsible for paying LSSC for their services in the processing and filing of applications for PAP programs and NOT for the medications.
I have paid and agree to a non-refundable application fee of $25.00 payable to LSSC to assist me in applying for free medications and a monthly membership fee of $20.00 per medication should they be successful in helping me obtain free medication. You agree that no prior-notification will be provided.
Any non-payment of fees may incur additional costs, including reasonable collection costs as determined by LSSC. I understand this is a service based contract and is NOT INSURANCE. The monthly administrative service fee of $20.00 per medication which will be debited on the 4th or 22nd day of every month.
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Lone Star Script Care LLC in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day.
In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Lone Star Script Care LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment.
I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute these scheduled payments with my bank so long as the transaction corresponds to the terms indicated in this form.
You hereby acknowledge that you are not paying for medication(s) through the Lone Star Script Care's Prescription Assistance Program; rather I am paying for the administrative service of ordering, managing, tracking and refilling medications received through this program from pharmaceutical company patient assistance programs. I hereby authorize LSSC and/ or its agents to debit the account provided during my initial enrollment for all administrative service fees described in this Fees section. I also agree to pay any associated fees should my EFT (electronic fund transfer) Or Credit/Debit Card be returned unpaid by my financial institution.
I hereby acknowledge, consent and agree this agreement is for twelve (12) months commencing on the date I sign below and will automatically be renewed for twelve (12)-month terms thereafter. You may terminate this agreement at any time by providing a signed letter of cancellation. Cancellations can take up to 30 days to process. Upon termination you agree to be financially responsible for any outstanding balances. Due to the service- based nature of this program, there are no refunds. You agree that you may be contacted via telephone, cellular phone, text message or email through all numbers/addresses provided by you and authorize receipt of pre-recorded/artificial voice messages and/or use of an automated dialing service by us and/or our affiliates. By signing below, you further agree to release LSSC, its agents, employees, successors and assigns from any and all liability including legal fees and costs arising from medications taken by you which were procured through the our service. You further agree to indemnify and hold LSSC, its agents, employees, and successor and assigns harmless against any and all damages including legal fees and costs arising from third persons ingesting any medication procured for you through this program.
Eligibility: I understand that completing this form does not guarantee that I will qualify for any particular program. All of the information I have/will provide and the copies of the income documents or other information about me that I may provide are complete and true. I verify that the information provided in my application(s) are correct and accurate. I agree to provide LSSC with all requested documentation necessary to apply for the various PAP programs, including, but not limited to proof of income, prescriptions, Doctor's signatures and customer's signature on all applications, copy of Medicare card and/or insurance information, tax documents, etc. LSSC and its agents may ask for additional documents and information at any time, even if I am already enrolled to help me with free medicine if I am enrolled to help me with free medicine if I am enrolled. I affirm that the information provided on this form is complete and accurate. If you determine the information was not correct at the time you provided it to Lone Star Script Care LLC, nor if the information was accurate but is no longer accurate, will you immediately notify LSSC in writing by providing the correct information. I currently have no prescription drug coverage for the medications I am requesting assistance with. You further agree to indemnify and hold LSSC, its agents, employees, and successor and assigns harmless against any and all damages including legal fees and costs arising from participation in this program. It will take approximately 4-6 weeks to start receiving your first supply of medication(s). I understand that completing this enrollment does not ensure that I will qualify for this program. I understand this is a service based contract and is NOT INSURANCE and that I am entering into a membership based program and that I should not stop with my current method of obtaining my medications until I have been approved for assistance.