STEP 2: Physician Contact Consent Form

Authorization*
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.
- Yes, I agree to all
- No, I do not agree
Complete if Applicable:
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
Signature of Patient:*
Date:
MM slash DD slash YYYY
Signature of Patient Respresentative (If Applicable):*
Name and Relationship
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Olivia Michelle

Founder, CEO of evermed

STEP 2: Physician Contact Consent Form

I CERTIFY THAT I HAVE READ THIS FORM AND THAT I UNDERSTAND ITS CONTENTS

Olivia Michelle

Our Company

Community

HIPAA