Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If you selected other, please specify. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What is the best phone number to reach you at? {{ 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 your 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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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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Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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