Eckard's Drug Co. record of Lisa McPherson prescription

[RX ] THIRD PARTY INSURANCE CLAIM LOG (STORE STAMP HERE)
[LOGO] Please have the patient, guardian or legal representative who has
received this prescription listed below read this statement and sign
for the appropriate prescription.

INSURANCE CLAIM LOG
Your signature certifies 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 identfied below and authorize release of all the
information contained on this log and prescription to which it
corresponds, to the plan administrator, the underwriter, the sponsor,
the policyholder and the employer. You further certify that this
medication is not for treatment of an on-the-job injury, and you
hereby assign to this provider pharmacy any payment due pursuant to
this transaction and authorize payment directly to this provider
pharmacy.

FOR MEDICAID RECIPIENTS ONLY:
Your signature certifies that you received a service or item dispensed
on the date listed below. You understand that 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 may be prosecuted
under applicable Federal and State Laws. You have read and agree with
the above statements.

DATE THIRD PARTY
DISPENSED RX NO. PATIENT I.D. PROGRAM
----------------------------------------------------------------------

[this table contains 24 prescription entries, all but one have patient's
name, the prescribed drug and doctor's name blacked out with a marker pen.
Prescription entry #9 on the form is for Lisa McPherson. It reads:]

**R.Ph.** COUNSELING ACCEPTED YES NO [1]
11/29/95 RX:907960 PL: 1
ID:
MCPHEARSON,LIS[2] [Signature of ?M.S.Schiebeger?]

[1] - In the "Counseling Accepted" field, neither the yes or no value was
indicated
[2] - Misspelling of Lisa McPherson's name is in the original document.

============================================================================ G Li
TIF5077 OCR and [bracketed] comments by Michael Reuss

#106872