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Niskayunacsdmeds enrollment package 01.15

Introduction:
NiskayunaCSDMeds is an international mail order option provided through CanaRx for all
eligible Employees, Retirees and qualifying Dependents of the Niskayuna Central School
District, Niskayuna, New York. For your convenience, a list of eligible medications is located
on the back of this page.
Copayments:
All member copayments have been waived for this program only.
NiskayunaCSDMeds Vs. Current local purchase plan
Annual Cost
Current Retail
Annual Copay
No Copays!
$20 (Brand)
12 = $240 / Script
Vs. $40 (Non-formulary) x
12 = $480 / Script
Ordering Instructions:
To place your first order simply complete the enrollment form and include a new prescription for each
medication. Please allow 4 weeks for delivery.
Ask your doctor for a prescription for a 3 month supply with 3 refills. We will call you prior to each
renewal to ensure that you have a continuous supply.
Medications must be tried for 30 days before ordering through NiskayunaCSDMeds.
RETURN YOUR COMPLETED AND SIGNED ENROLLMENT FORM AND ORIGINAL PRESCRIPTIONS:
BY FAXING TO: 1-866-715-MEDS (6337) TOLL FREE
Faxed prescriptions are ONLY accepted if sent directly from the physician's office.
BY MAILING TO: NiskayunaCSDMeds
Detroit, MI 48244-0650
More forms are available:
Additional forms may be obtained from your Human Resources Department, printing them from
www.NiskayunaCSDMeds.com or by contacting our Customer Service Representatives toll free at
1-866-893-(MEDS) 6337.

WELCOME TO
For More Information: Call 1-866-893-MEDS (6337)
TAZORAC CREAM 0.1% NIASPAN (G) 500MG
TAZORAC GEL 0.05% GLUMETZA ER 1000MG NIASPAN (G) 750MG
TAZORAC GEL 0.1% IMITREX AUTOINJECTOR
NIASPAN (G) 1000MG
STAT (G) 6MG/0.5ML
CYMBALTA (G) 20MG
IMITREX NASAL SPRAY (G)
ABILIFY DISCMELT 10MG CYMBALTA (G) 30MG
5MG-2DOSE
OMNARIS NASAL SPRAY 50MCG TEKTURNA 300MG ABILIFY DISCMELT 15MG CYMBALTA (G) 60MG
IMITREX NASAL SPRAY (G)
TEKTURNA HCT 150-12.5MG ABILIFY SOLUTION 1 MG/ML 20MG-2DOSE
TEKTURNA HCT 300-12.5MG ACCOLATE (G) 20MG
DETROL (G) 1MG
INDERAL LA (G) 60MG
OPTIVAR (G) 0.05%
TEKTURNA HCT 300-25MG ACIPHEX (G) 20MG
DETROL (G) 2MG
INDERAL LA (G) 80MG
TEVETEN HCT 600/12.5MG DETROL LA (G) 2MG
INDERAL LA (G) 120MG
ORTHO-TRI-CYCLEN LO DETROL LA (G) 4MG
INDERAL LA (G) 160MG
TOBREX OINT 0.3% DEXILANT DR 30MG PATANOL OPHTH SOL 0.1% DEXILANT DR 60MG ACTOPLUS (G) 15MG-850MG
DIFFERIN GEL 0.3% ACTOS (G) 15MG
ACTOS (G) 30MG
ACTOS (G) 45MG
PREMARIN 0.625MG TRAVATAN Z OPHTH SOL JALYN 0.5MG/0.4MG ADVAIR DISKUS 100MCG DIOVAN HCT (G) 80/12.5MG
JANUMET 50/500MG PREMARIN VAG 0.625MG/GM TRIBENZOR 20/5/12.5MG ADVAIR DISKUS 250MCG DIOVAN HCT (G) 160/12.5MG
JANUMET 50/1000MG PREMPRO 0.3/1.5MG TRIBENZOR 40/5/12.5MG ADVAIR DISKUS 500MCG DIOVAN HCT (G) 160/25MG
JANUMET XR 50MG/1000MG PREMPRO 0.625MG/2.5MG TRIBENZOR 40/10/12.5MG ADVAIR HFA 45/21 MCG DIOVAN HCT (G) 320/12.5MG
PREMPRO 0.625MG/5MG TRIBENZOR 40/5/25MG ADVAIR HFA 115/21 MCG DIOVAN HCT (G) 320/25MG
PREVACID (G) 30MG
TRIBENZOR 40/10/25MG ADVAIR HFA 230/21 MCG PREVACID SOLUTAB 15MG TRICOR (G) 48MG
AGGRENOX 200/25MG JENTADUETO 2.5MG/850MG PREVACID SOLUTAB 30MG TRICOR (G) 145MG
ALOCRIL OPHTH 2% JENTADUETO 2.5MG/1000MG TRUVADA 200-300MG DULERA 100MCG/5MCG KAZANO 12.5/1000MG TUDORZA PRESSAIR 400MCG ALPHAGAN-P OPHTH SOL (G)
DULERA 200MCG/5MCG PROMETRIUM (G) 100MG
DYMISTA NASAL SPRAY PROMETRIUM (G) 200MG
ALVESCO 80MCG 100MCG PROTOPIC OINT 0.03% ALVESCO 160MCG 200MCG PROTOPIC OINT 0.1% QVAR 40MCG 50MCG EDARBYCLOR 40MG/12.5MG QVAR 80MCG 100MCG UROXATRAL (G) 10MG
ARCAPTA NEOHALER 75MCG EDARBYCLOR 40MG/25MG ARTHROTEC (G) 50MG
LEXAPRO (G) 5MG
ARTHROTEC (G) 75MG
LEXAPRO (G) 10MG
VENTOLIN HFA 90MCG LEXAPRO (G) 20MG
VERAMYST 27.5MCG ASMANEX TWISTHALER ASTELIN (G) 137MCG
ATACAND (G) 32MG
VIRAMUNE XR 400MG ATRIPLA 600-200-300MG LIPITOR (G) 10MG
ATROVENT HFA 20UG LIPITOR (G) 20MG
VIVELLE-DOT 25MCG LIPITOR (G) 40MG
VIVELLE-DOT 37.5MCG AVANDAMET 4MG/500MG LIPITOR (G) 80MG
RETIN A MICRO GEL (G) 0.04%
VIVELLE-DOT 50MCG AVANDAMET 4MG/1000MG EPIDUO 0.1%/2.5% RETIN A MICRO GEL (G) 0.1%
VIVELLE-DOT 75MCG RETIN-A MICRO GEL (G)
VIVELLE-DOT 100MCG AVAPRO (G) 300MG
EPIPEN JR 0.15MG LUMIGAN OPHTH 0.01% 0.1%PUMP
EPIVIR / HBV (G) 100MG
LUMIGAN OPHTH 0.03% REVATIO (G) 20MG
MAXALT (G) 5MG
RHINOCORT AQ 32MCG AZOPT OPHTH DROPS 1% ESTROGEL GEL 0.06% MAXALT (G) 10MG
RHINOCORT AQ 64MCG MAXALT MELT (G) 5MG
RILUTEK (G) 50MG
MAXALT MELT (G) 10MG
MESTINON TS 180MG EXELON 4.6 MG/24HR SEREVENT DISKUS 50MCG EXELON 9.5MG/24HR MICARDIS (G) 20MG
SEROQUEL (G) 25MG
BECONASE AQ 0.04% EXELON 13.3MG/24HR MICARDIS (G) 40MG
SEROQUEL XR 50MG YASMIN 28 (G)
MICARDIS (G) 80MG
SEROQUEL XR 150MG MICARDIS HCT (G) 40/12.5MG
SEROQUEL XR 200MG BENICAR HCT 20MG/12.5MG EXFORGE 10/160MG MICARDIS HCT (G) 80/12.5MG
SEROQUEL XR 300MG BENICAR HCT 40MG/12.5 MG EXFORGE 10/320MG MICARDIS HCT (G) 80/25MG
SEROQUEL XR 400MG BENICAR HCT 40MG/25 MG EXFORGE HCT 160/12.5/5MG MIGRANAL NASAL SPRAY SINGULAIR (G) 5MG
EXFORGE HCT 160/12.5/10MG SINGULAIR (G) 10MG
EXFORGE HCT 160/25/5MG MIRAPEX ER 0.375MG EXFORGE HCT 160/25/10MG MIRAPEX ER 0.75MG STARLIX (G) 60MG
BONIVA (G) 150MG
EXFORGE HCT 320/25/10MG MIRAPEX ER 1.5MG STARLIX (G) 120MG
BREO ELLIPTA 100/25MCG EXTAVIA KIT 0.3MG MIRAPEX ER 2.25MG MIRAPEX ER 3.75MG CADUET (G) 5/10MG
MIRAPEX ER 4.5MG CADUET (G) 5/20MG
FLONASE (G) 50MCG
CADUET (G) 5/40MG
FLOVENT 44MCG 50MCG CADUET (G) 10/10MG
FLOVENT 110MCG 125MCG MYFORTIC (G) 180MG
CADUET (G) 10/20MG
FLOVENT 220MCG 250MCG FLOVENT DISKUS 50MCG FLOVENT DISKUS 100MCG FLOVENT DISKUS 250MCG FORADIL + AEROLIZER 12MCG FOSAMAX-D 70/2800MG FOSRENOL CHEW 500MG CLARINEX (G) 5MG
FOSRENOL CHEW 750MG CLIMARA PRO 0.045/0.015 FOSRENOL CHEW 1000MG COMBIGAN 0.2-0.5% COMPLERA 200/25/300MG TAZORAC CREAM 0.05% NOTE: Medication names appearing with (G) are available in a Generic version from your local or U.S. mail order pharmacy. For a greater
savings to your healthcare plan, ask your physician about taking a Generic equivalent of your medication.
This list is subject to change. Please call 1-866-893-6337 toll free to verify the availability of your medication through this program. January 2015 Associate Enrollment Form
MEMBER ID #:
FAX DIRECTLY FROM YOUR DOCTOR'S OFFICE WITH YOUR PRESCRIPTION (S) TOLL-FREE TO: 1-866-715-(MEDS) 6337
MAIL TO: NiskayunaCSDMeds, P.O. BOX 44650, DETROIT, MI., 48244-0650 PHONE TOLL-FREE: 1-866-893-(MEDS) 6337
PATIENT INFORMATION:
Birthdate
DD/MM/YYYY
Please request a 3-month supply
of medication with 3 refills.

New-to-you medications must be
First Name (please print)
Last Name
domestically prescribed, filled and taken for a period of no less than Street Address

City/State
List all pr
escription,
non-prescription, over-the-counter
Strength
Reason for Taking
Daily Use
medications, herbal, nutritional and vitamin supplements and
their strengths. Ex. Lipitor (This is NOT a prescription.)
Ex. 10 mg Ex. Cholesterol Ex. Twice Daily
MEDICAL HISTORY (If you require more space, please attach a separate piece of paper.)
Male Female

(i) Operations: e.g., Hysterectomy, Gall bladder, Heart operations, etc.


(ii) Hospitalizations: (stays in hospital during the past 5 years)

(iii) Present illness: (ongoing) e.g., Diabetes, Heart disease, Osteoporosis, etc.
(iv) Drug allergies:  NO YES If yes, please specify:

AUTHORIZATION
I confirm that a U.S. Physician will regularly monitor me and that I have had a physical examination within the past 12 months. I
verify that I have taken the above listed medications for a period of more than 30 days. I certify that I have read, understand and
agree to the Terms of Agreement on the reverse and that the information provided by me is accurate and true.
I request and authorize Niskayuna Central School District, Niskayuna, New York as my appointed agent, to pay for any and all
services, fees and amounts relating to the prescription medications that I will obtain through this service as determined appropriate
by Niskayuna Central School District, Niskayuna, New York in the administration of my employment benefits.

Subscriber Signature:
Date: (DD/MM/YY)
CONFIRMATION AND REPRESENTATIONS
I, the undersigned, am entering into this agreement with CanaRx Group Inc. ("CanaRx") in order that I may obtain access to
medically necessary prescription drugs at low costs.
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; The medications that I have requested that CanaRx facilitate my obtaining were prescribed by a duly qualified and licensed medical practitioner in the 4. I have not violated any laws in the jurisdiction in which I ordinarily reside, in obtaining the prescription for the ordered product; 5. This prescription has not been altered in any way nor has it been filled previously. I agree to mail or fax from my doctor's office the original copy of the prescription to CanaRx; I am under the ongoing care of a physician in my residing jurisdiction (my "U.S. physician"), and therefore, I am not seeking or relying on any medical information from CanaRx or any CanaRx contracted physician; My prescription will not be used in any way whatsoever except as prescribed by my medical practitioner who originally issued the prescription; I will not permit anyone else to use the prescription or any medications which I receive; I will use any medications obtained for me by CanaRx strictly in accordance with the instructions provided by the physician who prescribed the medications; and 10. In the event that I suffer any side effects from any medications I receive through the services of CanaRx, I will immediately contact my U.S. physician. 11. I certify that I am a resident of the United States and not a resident of any other country. AUTHORIZATION AND CONSENT
I further provide my authorization and consent to the following:
I hereby appoint CanaRx and its delegates or contractors as my paid agent and attorney for the purposes of obtaining prescriptions which correspond to the prescriptions provided by my U.S. physician. I authorize CanaRx and its delegates or contractors to arrange the purchase and delivery of the medications prescribed to me on the terms outlined in this agreement and to the same extent as if I personally took such steps. 3. I consent and authorize CanaRx to collect my personal medical information and to maintain on file the information necessary to verify and process future orders, including but not limited to my full name, address, phone number, complete medical history and payment information. I authorize my U.S. physician and CanaRx to release any and all information required in connection with my physical condition, including but not limited to all X-rays, medical records, medical reports, progress notes, nurses' notes, reports on diagnostic tests, medical opinions and/or any other knowledge or information which they may possess to a CanaRx contracted physician who may be required to review my health record for the purposes of being in a position to evaluate the medical necessity and indications for prescription medication. I authorize the CanaRx contracted physician to contact my U.S. physician to discuss my prescription if necessary. I further authorize the CanaRx contracted physician to issue prescriptions for medications I have ordered only if he/she deems it advisable and 7. I further authorize the CanaRx contracted physician to release any and all information that may be required by any CanaRx contracted pharmacy for the purpose of having my prescriptions filled. 8. I further authorize CanaRx to make payments on my behalf to the CanaRx contracted pharmacy for the filling of my prescriptions and to the CanaRx contracted physician for services rendered on my behalf. ACKNOWLEDGEMENT AND RELEASE
I hereby make the following acknowledgments and releases to CanaRx, including all of its employees, its contractors, including
physicians, pharmacists, pharmacy technicians, nurses, receptionists and staff:
I acknowledge that my U.S. physician is my primary physician and the CanaRx contacted physician is being asked only to review the information contained in the Personal Medical History for the purpose of authorizing any properly prescribed medications for fulfillment from a CanaRx contracted pharmacy. 2. I acknowledge that CanaRx 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). 3. I acknowledge that I wish to obtain a prescription from a CanaRx contracted physician and have enlisted the services of CanaRx to facilitate this matter. I understand and appreciate that the CanaRx contracted physician will rely on the accuracy of the examination and prescription provided by my U.S. I hereby specifically acknowledge that I am aware that CanaRx may transmit my personal information by electronic means (for example fax, or secure 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 CanaRx, 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 CanaRx's transmission of my personal information by electronic means to its agents, contracted physicians and pharmacies. 5. I release CanaRx and all of their officers and directors, agents, employees and contractors from any and all 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 understand that my medications may be subject to U.S. border seizure. I specifically confirm, acknowledge and agree that title to my medication passes to me when my medications are shipped from the CanaRx contracted pharmacy. I acknowledge that CanaRx, as my paid agent, requires payment in full prior to shipment and that my order may not be returned for a refund or an exchange.
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 regard- ing 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 herby release CanaRx Group and all its officer, directors, agents, 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 packaging in filling my prescription . 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 CanaRx Group Inc. in obtaining the prescription medications to fill my order; (iii) any and all causes of actions regarding the use of any medications delivered through this program which are utilized for any purpose whatsoever. Spouse/Dependent Enrollment Form
MEMBER ID #:
FAX DIRECTLY FROM YOUR DOCTOR'S OFFICE WITH YOUR PRESCRIPTION(S) TOLL-FREE TO: 1-866-715-(MEDS) 6337
MAIL TO: NiskayunaCSDMeds, P.O. BOX 44650, DETROIT, MI., 48244-0650 PHONE TOLL-FREE: 1-866-893-(MEDS) 6337
PATIENT INFORMATION: Birthdate
DD/MM/YYYY DEPENDENT
Please request a 3-month supply
of medication with 3 refills.
First Name (please print)
Last Name
New-to-you medications must be
domestically prescribed, filled and taken for a period of no less than Street Address
City/State
List all prescription, non-prescription, over-the-counter
Strength
Reason for Taking
Daily Use
medications, herbal, nutritional and vitamin supplements and
their strengths. Ex. Lipitor (This is NOT a prescription.)
Ex. 10 mg Ex. Cholesterol Ex. Twice Daily
MEDICAL HISTORY (If you require more space, please attach a separate piece of paper.)
Male Female

(i) Operations: e.g., Hysterectomy, Gall bladder, Heart operations, etc.
(ii) Hospitalizations: (stays in hospital during the past 5 years)

(iii) Present illness: (ongoing) e.g., Diabetes, Heart disease, Osteoporosis, etc.
(iv) Drug allergies:  NO YES If yes, please specify:

AUTHORIZATION IF THE PATIENT IS A DEPENDENT CHILD UNDER AGE 18
I certify this to be a true and accurate statement of my Dependent's medical history. I confirm that he/she has been, and will be, regularly
monitored by a U.S. Physician and has had a physical examination within the past 12 months. I verify that he/she has taken the above listed
medications for a period of more than 30 days. I certify that I have read, understand and agree to the Terms of Agreement on the reverse and that
the information provided above is accurate and true. I request and authorize Niskayuna Central School District, Niskayuna, New York as my
authorized agent, to pay for any and all services, fees and amounts relating to the prescription medications that I will obtain through this service.

Parent's/Guardian's Signature
Date: (DD/MM/YY)

AUTHORIZATION IF THE PATIENT IS THE SPOUSE OR A DEPENDENT CHILD AGE 18 AND OVER
I confirm that a U.S. Physician will regularly monitor me and that I have had a physical examination within the past 12 months. I verify that I have
taken the above listed medication for a period of more than 30 days. I certify that I have read, understand and agree to the Terms of Agreement on
the reverse and that the information provided by me is accurate and true. I request and authorize Niskayuna Central School District, Niskayuna,
New York as my authorized agent, to pay for any and all services, fees and amounts relating to the prescription medications that I will obtain
through this service.

Patient Signature:
Date: (DD/MM/YY)
CONFIRMATION AND REPRESENTATIONS
I, the undersigned, am entering into this agreement with CanaRx Group Inc. ("CanaRx") in order that I may obtain access to
medically necessary prescription drugs at low costs.
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; The medications that I have requested that CanaRx facilitate my obtaining were prescribed by a duly qualified and licensed medical practitioner in the 4. I have not violated any laws in the jurisdiction in which I ordinarily reside, in obtaining the prescription for the ordered product; 5. This prescription has not been altered in any way nor has it been filled previously. I agree to mail or fax from my doctor's office the original copy of the prescription to CanaRx; I am under the ongoing care of a physician in my residing jurisdiction (my "U.S. physician"), and therefore, I am not seeking or relying on any medical information from CanaRx or any CanaRx contracted physician; My prescription will not be used in any way whatsoever except as prescribed by my medical practitioner who originally issued the prescription; I will not permit anyone else to use the prescription or any medications which I receive; I will use any medications obtained for me by CanaRx strictly in accordance with the instructions provided by the physician who prescribed the medications; and 10. In the event that I suffer any side effects from any medications I receive through the services of CanaRx, I will immediately contact my U.S. physician. 11. I certify that I am a resident of the United States and not a resident of any other country. AUTHORIZATION AND CONSENT
I further provide my authorization and consent to the following:
I hereby appoint CanaRx and its delegates or contractors as my paid agent and attorney for the purposes of obtaining prescriptions which correspond to the prescriptions provided by my U.S. physician. I authorize CanaRx and its delegates or contractors to arrange the purchase and delivery of the medications prescribed to me on the terms outlined in this agreement and to the same extent as if I personally took such steps. 3. I consent and authorize CanaRx to collect my personal medical information and to maintain on file the information necessary to verify and process future orders, including but not limited to my full name, address, phone number, complete medical history and payment information. I authorize my U.S. physician and CanaRx to release any and all information required in connection with my physical condition, including but not limited to all X-rays, medical records, medical reports, progress notes, nurses' notes, reports on diagnostic tests, medical opinions and/or any other knowledge or information which they may possess to a CanaRx contracted physician who may be required to review my health record for the purposes of being in a position to evaluate the medical necessity and indications for prescription medication. I authorize the CanaRx contracted physician to contact my U.S. physician to discuss my prescription if necessary. I further authorize the CanaRx contracted physician to issue prescriptions for medications I have ordered only if he/she deems it advisable and 7. I further authorize the CanaRx contracted physician to release any and all information that may be required by any CanaRx contracted pharmacy for the purpose of having my prescriptions filled. 8. I further authorize CanaRx to make payments on my behalf to the CanaRx contracted pharmacy for the filling of my prescriptions and to the CanaRx contracted physician for services rendered on my behalf. ACKNOWLEDGEMENT AND RELEASE
I hereby make the following acknowledgments and releases to CanaRx, including all of its employees, its contractors, including
physicians, pharmacists, pharmacy technicians, nurses, receptionists and staff:
I acknowledge that my U.S. physician is my primary physician and the CanaRx contacted physician is being asked only to review the information contained in the Personal Medical History for the purpose of authorizing any properly prescribed medications for fulfillment from a CanaRx contracted pharmacy. 2. I acknowledge that CanaRx 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). 3. I acknowledge that I wish to obtain a prescription from a CanaRx contracted physician and have enlisted the services of CanaRx to facilitate this matter. I understand and appreciate that the CanaRx contracted physician will rely on the accuracy of the examination and prescription provided by my U.S. I hereby specifically acknowledge that I am aware that CanaRx may transmit my personal information by electronic means (for example fax, or secure 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 CanaRx, 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 CanaRx's transmission of my personal information by electronic means to its agents, contracted physicians and pharmacies. 5. I release CanaRx and all of their officers and directors, agents, employees and contractors from any and all 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 understand that my medications may be subject to U.S. border seizure. I specifically confirm, acknowledge and agree that title to my medication passes to me when my medications are shipped from the CanaRx contracted pharmacy. I acknowledge that CanaRx, as my paid agent, requires payment in full prior to shipment and that my order may not be returned for a refund or an exchange.
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 regard- ing 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 herby release CanaRx Group and all its officer, directors, agents, 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 packaging in filling my prescription . 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 CanaRx Group Inc. in obtaining the prescription medications to fill my order; (iii) any and all causes of actions regarding the use of any medications delivered through this program which are utilized for any purpose whatsoever.

Source: http://www.niskyschools.org/staffresources/PDFs/2016_Updates/2015%20NiskayunaCSDMeds%20Enrollment%20Package%2001%2015.pdf