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 CONTENTSSignature of Patient:*Date: MM slash DD slash YYYY Signature of Patient Respresentative (If Applicable):*Name and Relationship CAPTCHA Odio vel in nunc aenean dignissim dignissim mattis elementum id sed senectus laoreet blandit faucibus vitae quam aliquam nibh lacus, rhoncus massa placerat urna. Olivia Michelle Founder, CEO of evermed