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Your signature on this form certifies you received a service or item dispensed on the date(s) listed and that the information contained hereon is correct and that the person for whom the prescription was written is eligible for the benefits. You also certify that you have received the medication identified below and authorize release of all the information contained on this log and prescription to which it corresponds, to the plan administrator, the underwitted, the sponsor, the policyholder, the Workman’s Compensation Commission (if applicable), and the employer. You hereby assign to this provider pharmacy any payment due to pursuant to this transaction and authorize payment directly to this provider pharmacy. In addition: You understand that if payment for this service or item will be from Federal and State funds and that any false claims, statements or documents, or concealment of material facts may be prosecuted under applicable Federal and State Laws. Furthermore, as required by State Laws you acknowledge receipt of an OFFER TO COUNSEL and have accepted or refused counseling as indicated. WORKERS COMPENSATION ONLY: Your signature on the reverse side of this card certifies that this medication is for the treatment of an on-the-job injury. ALL OTHER THIRD PARTY PROGRAMS: Your signature on this form certifies that this medication is not for the treatment of an on-the-job injury.

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