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STEP 2: Physician Contact Consent Form

  • I agree to utilize ACORx Pharmacy for the packaging of my mediations in the easy to use compliance package format. I authorize ACORx Pharmacy to contact my previous pharmacy and physicians to obtain my current prescriptions to full my medication orders. I authorize ACORx Pharmacy to automatically refill my prescriptions. I have been offered notice of HIPAA private practices.
  • I have a personal representative who will act on my behalf with regards to my medications and ACORx Pharmacy and give full access to my private health information.
  • I CERTIFY THAT I HAVE READ THIS FORM AND THAT I UNDERSTAND ITS CONTENTS

  • MM slash DD slash YYYY
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Olivia Michelle

Founder, CEO of evermed

ATTENTION PATIENTS:

ACORx Pharmacy is moving locations on May 14th 2022.

Our new location is only one block away!

The new address is 441 Jane St. Carnegie, PA 15106.