Mail-Meds Clinical Pharmacy Enrollment Form

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What name do you go by? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you are assisting in filling out this form, please enter your name here {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your date of birth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Assigned Sex at Birth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the best number to reach you at? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What type of phone is this? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please identify who the number belongs to {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any drug allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list any drug allergies in the space below {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

What is your Social Security Number? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your current home address? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please take a photo of the FRONT of your Driver's License on your mobile device or PC and click upload.

DL Image {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please enter your Driver's License number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

JTJ Medical Supply, Inc. Communication Preferences

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How should we contact you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you do not answer the phone, may we leave a message with a name and call back phone number? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Describe Other Contact Type: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mail-Meds Clinical Pharmacy may deliver your medications and information about your medications. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Where would you like your medication and information about your medication delivered to? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you selected other, please provide address for delivery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have an emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your emergency contacts name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your relationship to emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the best phone number to reach your emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have a primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your primary caregivers name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your relationship to primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is the best phone number to reach your primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Use this space to provide the first and last name, relationship and phone number of people we are authorized to share and release your information to. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Do you have a case manager? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your case managers name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Although SMS/text messages communicated wirelessly are usually encrypted by the carrier, interception and decryption of such messages may be done.Text messages reside on a mobile device and carrier’s server indefinitely where the information may be exposed to unauthorized third parties due to theft,loss, or recycling of the device. By checking YES above you understand that texting is not a secure form of communication. Please approve or deny consent below. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter your cell phone number if you would like to receive text messages {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If we are emailing protected information we will use encrypted email service that is a secure form of communication. There is some risk that any individuallyidentifiable health information and other sensitive or confidential information that may be contained in any email may be misdirected, disclosed to orintercepted by unauthorized third parties. We will use the minimum necessary amount of protected health information (PHI) in any communication. Our first email to you will verify the email address you provide to us. Please approve or deny consent below. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter your email address if you would like to receive emails {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

By signing in the space provided, I certify all information is true and correct to the best of my knowledge. I acknowledge that I have authorized Mail-Meds Clinical Pharamcy to use of all information provided to communicate with me in the methods indicated above. Please sign below. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pharmacy Services and Preferences Questionnaire

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What language do you speak most often with your friends and family? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify your most spoken language in the space below {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Would you like an interpreter to assist you to clearly understand more about our pharmacy services? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What language would you like us to print your prescription labels and medication education materials in? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please specify what language you would like your prescription labels and medication education materials printed in {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you able to clearly read the directions on a prescription bottle of medicine? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Would you like large printed directions, talking labels, and/or braile to assist further? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What are your preferred pronouns? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your gender identity? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your sexual orientation? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please self-identify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please self-identify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have any cultural, religious beliefs, or preferences about your health care that you would like us to know to service you better? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes, please describe how the you manage them, what remedies have been tried, and the health outcomes. Please include the names and type of practice of any doctors or other healthcare professionals involved in your health treatment. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please use the space provided to tell us anything else about you that you would like to share. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

JTJ Medical Supply, Inc. Financial Information

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Including yourself, how many people live in your household? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your approximate annual gross HOUSEHOLD income? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you a legal US resident? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have Prescription Insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please take a photo of the FRONT of your insurance card on your mobile device or PC and click upload. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please take a photo of the BACK of your insurance card on your mobile device or PC and click upload. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please enter the name of your PRESCRIPTION Insurance provider {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter your member ID number located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter the Rx Group number located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter the Rx Bin number located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter the Rx PCN located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please enter the PRESCRIPTION insurance Customer Service Telephone number (if available) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Who is your doctor or provider? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list any other doctors or providers you are seeing. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Are you currently enrolled with ADAP? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What state are you enrolled with to receive ADAP benefits? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What state are you currently applying with to receive ADAP benefits? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

By signing in the space provided, I certify all information is true and correct to the best of my knowledge. I acknowledge that I have authorized Mail-Meds Clinical Pharmacy the use of all information provided to apply for financial assistance if needed. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

JTJ Medical Supply, Inc. Assignment of Benefits

Assignment of Benefits: I hereby authorize Medicare, Medicaid or my private health insurance plan to pay my drug and supplies benefit directly to JTJ Medical Supply, Inc. I authorize JTJ Medical Supply, Inc. to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. I further authorize any holder of medical information about me to release such information that may be required for JTJ Medical Supply, Inc. to file an insurance claim on my behalf. The original will be kept on file by JTJ Medical Supply, Inc. and a copy sent to my insurance plan when requested. Patient Responsibility: I agree that my insurance company’s verification of benefits does not release me from financial responsibility for services rendered. If my insurance company denies any claims, in part or whole, to include any deductible, co-insurance, co-payment or disallowance of payment, or the organization is an out-of-network provider, I am financially responsible for all charges not covered by my insurance. I understand the actual member financial responsibility will be determined when the claim is processed and I will be contacted by a JTJ Medical Supply, Inc. staff informing me of the cost prior to the delivery of the medication(s) and the costs will be provided to me both verbally and in writing. In the event of non-coverage, or if my insurance should pay benefits directly to me for any merchandise provided by JTJ Medical Supply, Inc., I will either endorse all checks from my insurance company as “Pay to the order of JTJ Medical Supply, Inc.” within seven (7) days of receipt of checks or provide payment to JTJ Medical Supply, Inc. in the form of a personal check or credit card.I agree to inform JTJ Medical Supply, Inc. of any change in my status including, but not limited to: change in address, hospital or nursing home admissions and discharges, and any changes that affect my insurance coverage and payments or my own ability to pay for products and services rendered by JTJ Medical Supply, Inc. and prescribed by my physician. If you have any questions regarding this form, please contact JTJ Medical Supply, Inc. at 2692 Oak Ridge Court, Fort Myers,FL 33901, (800) 939-2022. Please sign below {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

JTJ Medical Supply, Inc. HIPAA Privacy Notice

As required by HIPAA, all Patients who receive pharmacy services from JTJ Medical Supply, Inc. must sign below.Please note that the attached Notice is not a consent form. This form must be read in full and signed before services can be provided. This Notice provides our Patients with a summary description of (1) How our office will use and disclose medical and billing information for legitimate business purposes, and (2) How our Patients can exercise their rights with regard to his/her health information. This notice is similar to the one that you receive from your physician’s office and other institutions that provide medical care and services. Please confirm you have received the JTJ Medical Supply, Inc. Notice of Privacy Practices by signing below.Thank you!I have received the JTJ Medical Supply, Inc. Notice of Privacy Practices in the Enrollment/Welcome Packet/Handbook. By signing below I acknowledge that I have received the JTJ Medical Supply, Inc. Notice of Privacy Practices in the Enrollment/Welcome Packet/Handbook. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

JTJ Medical Supply, Inc. Welcome Packet Acknowledgement

I acknowledge that I received the Welcome Package that contains at least the following information: (1) Contact Information (2) Hours of Operation (3) Clinical Pharmacist After Hours Availability (4) Patient Clinical Management Program (5) Patient Bill of Rights and Responsibility (6) Patient Complaint Form (7) Request of Financial Assistance Information (8) Assignment of Benefits Form (9) Disposal of Medical Waste Clinical Management Standards (10) Patient Contact and Communications Consent (11) Notice of Privacy Practices (12) Customer Satisfaction Form. Please confirm you have received JTJ Medical Supply Specialty Pharmacy Welcome Packet by signing in the space provided. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please click the link below to view and download a copy of the Welcome Packet:

Welcome Packet

Please click 'SUBMIT' button below to complete this form.