Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What name do you go by? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you are assisting in filling out this form, please enter your name here {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your date of birth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the best number to reach you at? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please identify who the number belongs to {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please list any drug allergies in the space below {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your Social Security Number? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your current home address? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Please enter your Driver's License number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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JTJ Medical Supply, Inc. Communication Preferences
Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Describe Other Contact Type: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you selected other, please provide address for delivery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your emergency contacts name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your relationship to emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the best phone number to reach your emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your primary caregivers name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your relationship to primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the best phone number to reach your primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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What is your case managers name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please enter your cell phone number if you would like to receive text messages {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please enter your email address if you would like to receive emails {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pharmacy Services and Preferences Questionnaire
Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please specify your most spoken language in the space below {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please specify what language you would like your prescription labels and medication education materials printed in {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please self-identify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please self-identify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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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 }
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JTJ Medical Supply, Inc. Financial Information
Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Including yourself, how many people live in your household? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is your approximate annual gross HOUSEHOLD income? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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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 }
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Please enter the name of your PRESCRIPTION Insurance provider {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please enter your member ID number located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please enter the Rx Group number located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please enter the Rx Bin number located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please enter the Rx PCN located on your PRESCRIPTION insurance card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please enter the PRESCRIPTION insurance Customer Service Telephone number (if available) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Who is your doctor or provider? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please list any other doctors or providers you are seeing. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What state are you enrolled with to receive ADAP benefits? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What state are you currently applying with to receive ADAP benefits? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please click the link below to view and download a copy of the Welcome Packet:
Welcome Packet
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