JTJ Medical Supply, Inc. Communication Preferences

  1. { binding displayValue, mode=oneTime }
Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
How should we contact you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
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 firstError.message }
Mail-Meds Clinical Pharmacy may deliver your medications and information about your medications. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Where would you like your medication and information about your medication delivered to? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If you selected other, please provide address for delivery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Do you have an emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What is your emergency contacts name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Do you have a primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What is your primary caregivers name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Do you have a case manager? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
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 firstError.message }
{ binding firstError.message }
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 firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{# pageNumbers}

JTJ Medical Supply, Inc. HIPAA Privacy Notice

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

JTJ Medical Supply, Inc. Communication Preferences

JTJ Medical Supply, Inc. Communication Preferences

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How should we contact you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If you selected other, please specify. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is the best phone number to reach you at? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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}
{ binding firstError.message }
Mail-Meds Clinical Pharmacy may deliver your medications and information about your medications. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Where would you like your medication and information about your medication delivered to? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If you selected other, please provide address for delivery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you have an emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is your emergency contacts name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is your relationship to emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is the best phone number to reach your emergency contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you have a primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is your primary caregivers name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is your relationship to your primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is the best phone number to reach your primary caregiver? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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 }
{ binding firstError.message }
Do you have a case manager? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is your case managers name? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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}
{ binding firstError.message }
Please enter your cell phone number if you would like to receive text messages {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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}
{ binding firstError.message }
Please enter your email address if you would like to receive emails {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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 }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

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