As required by HIPAA, all Patients who receive pharmacy services from JTJ Medical Supply, Inc. must:

• Sign the “Acknowledgement” Form below and return it to us for our records.

Please note that the attached Notice is not a consent form that must be read in full and signed before services can be provided; rather, the 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 then returning this form in the enclosed postage-paid envelope.

Thank you!

I have received the JTJ Medical Supply, Inc. Notice of Privacy Practices in the Enrollment/Welcome Package/Handbook.

Patient Signature: ________________________________________________________________________________________________    Date: _______________

Print Name: _______________________________________________________________________________________________________________________________

Address- Street: ___________________________________________________________________________________________________________________________

City: _____________________________________________________________________________     State:_______________    Zip Code:   ____________________

Patient Contact and Communication Consent to Share Information

Mail-Meds Clinical Pharmacy are required by the new HIPAA Privacy Rules to obtain your consent in order to share your medical information for certain reasons.

The Patient Contact and Communications Consent form on page 27 below will be in effect for as long as Mail-Meds Clinical Pharmacy supply your medication to you. You may withdraw this consent at any time by contacting our Health Benefits Coordinators at (800) 939-2022 option 4.

Mail-Meds Clinical Pharmacy will share this information with the people that you choose to arrange for delivery of your medication, discuss your treatment or discuss payment. This information may then be further disclosed in order to avoid any delay in delivering your medication delivery.

To inform us on how you would like us to communicate with you and to whom we may give information to please complete the form below and return it to us in the enclosed postage-paid envelope.

Thank you!

Patient Contact and Communications Consent

Please click here to fill out the Patient Contact and Communications Consent.

Patient Concerns and Complaints

You have the right and responsibility to express concerns, dissatisfaction or make complaints about services you do or do not receive without fear of reprisal, discrimination or unreasonable interruption of services.

JTJ Medical Supply, Inc.’s corporate office telephone number is (800) 939-2022. Should you call during regular business hours, please ask to speak with the General Manger of Pharmacy Operations at extension 3032. If you are calling outside of regular business hours (including weekends and holidays) please ask to speak to the on-call staff pharmacist. A formal written complaint may be filed as well. Please see page 29 below for a copy of our Patient Concern and Complaint form.

Mail-Meds Clinical Pharmacy have a formal complaint process that ensures that your concerns/complaints will be reviewed and investigated. Every attempt shall be made to resolve all grievances within five (5) business days of receipt of the concern/complaint. You will be informed by phone, and in writing if we cannot reach you by phone, of the resolution of the complaint. If more time is needed to resolve the concern/complaint, you will also be informed verbally and in writing.

If you feel the need to discuss your concerns, dissatisfaction or complaints with anyone other Mail-Meds Clinical Pharmacy, you have the right to express complaints to the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, DC 20201; or you may call (202) 619-0257 or 1-877-696-6775 (toll free); or you may log on to their internet address.

If you wish, you may also file a complaint with URAC (Utilization Review Accreditation Commission) at (202) 216-9010 or with ACHC (The Accreditation Commission for Health Care) at 1-855-937-2242 or 919-785-1214 and request the Complaints Department.

If you need to file a complaint against the pharmacy or one of our employees, please visit the Florida Department of Health website http://www.floridahealth.gov/licensing-and-regulation/enforcement/report-unlicensed-activity/file-a-complaint.html or call  (877) 425-8852.

JTJ MEDICAL SUPPLY, INC.
Patient Concern and Complaint Form

JTJ Medical Supply, Inc.’s staff strives to ensure that quality products/services are consistent with our philosophy. As stated in the Patient Bill of Rights and Responsibilities, you have the right to be given appropriate and professional quality pharmacy services without discrimination. You also have the right to voice your concerns, grievances, or complaints about your service without being retaliated or discriminated against.

If you are unhappy with our service or have concerns about safety and quality of care, we would like you to contact our management. You may either complete this form by clicking here and submitting a complaint form or call us at the number (800) 939-2022 or visit our website at www.mailmeds.com to submit your concerns.

Within one (1) business day of receiving your concern, we will notify you by telephone, email, fax or letter format that the matter is under investigation. No later than five (5) business days of receiving your concern, JTJ Medical Supply, Inc. will provide verbal or written notification to you with the results of its investigation and response.

Mail this Form to:
JTJ Medical Supply, Inc., P.O. Box 62134, Fort Myers, FL 33906-9987 or Fax to (855) 523-0910

Thank you in advance for bringing your concern to our attention as it will assist us in our continuing effort to improve the quality of our services.

Your Name: _______________________________________________________________________________________________________    Date of Birth: _________________________

Description of the Problem, Concern, or Complaint (include dates, times and names, if possible):

___________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________

Completed By (signature): _________________________________________________________________________________________________    Date: _________________________________

Relationship to Patient (if applicable): ____________________________________________________________________________________________________________________________

FINANCIAL OBLIGATIONS AND FINANCIAL ASSISTANCE

Insurance Claims

Mail-Meds Clinical Pharmacy will automatically submit prescription claims to your health insurance carrier based on the date your prescription is filled. You will receive a monthly statement if you are financially responsible for any portion of the prescribed medication. Please notify Mail-Meds Clinical Pharmacy of any change in your billing address or insurance information. If the prescription claim is rejected, the staff of Mail-Meds Clinical Pharmacy will notify you so that we can work together to resolve the issue. If we are unable to resolve the issue, our staff will provide you with information on how to file a claim. You may be responsible for paying a coinsurance and/or deductible amount. Please see “Assignment of Benefits” on page 32 (below) for further information on payments and responsible parties.

Co-Payments

In almost all cases, Mail-Meds Clinical Pharmacy are required to collect all insurance co-payments prior to the delivery or pick-up of your prescription medication(s). Mail-Meds Clinical Pharmacy accept all major credit and debit cards (over the telephone or in-person) and also accepts personal checks and money orders at prescription pick-up or as payment in advance through the mail.

Outstanding Balances

If for any reason you owe a balance, the balance must be paid prior to your next prescription refill. Mail-Meds Clinical Pharmacy accept all major credit and debit cards (Visa, MasterCard, American Express and Discover) and also accepts personal checks and money orders.

Payment Plan

If you need help in arranging a payment plan for the money you owe, please contact our Billing Department at (800) 939-2022 option 6. If you receive a check directly from your insurance provider or prescription plan for prescriptions dispensed to you by either Mail-Meds Clinical Pharmacy, you should immediately endorse the check (sign the back) and mail it to: Mail-Meds Clinical Pharmacy, Attn: Billing Dept., P.O. Box 62134, Ft. Myers, FL 33906-9987. Please include a copy of the Explanation of Benefits (also known as the EOB) that accompanied the check when you received it.

Co-pay Assistance Referral Program

Mail-Meds Clinical Pharmacy submit claims to your health insurance carrier on the date your prescription is filled. If the claim is rejected for out of network or there is a high out-of-pocket cost such as deductibles, co-pays, co-insurance, and out-of-network information a pharmacy staff member will notify you so that we can work together to resolve the issue. We will also provide you a claim print out (Medical Expense Report) in writing.

Mail-Meds Clinical Pharmacy will attempt to identify any possible Co-pay Assistance Referral Programs that may offer financial assistance to help you with out-of-pocket costs such as deductibles, co-pays, and/or co-insurance to ensure there is no interruptions in your therapy. These programs include discount coupons from drug manufacturers, co-payment vouchers, and assistance from various disease management foundations and pharmaceutical companies.

You will always be informed of high co-payments prior to filling of the medication. We will explore all additional resources to help address these. If there are no financial resources available we will work with your physician to explore alternatives for you.

If you are in need of co-pay assistance, please complete the following form on page 32 below and return it to your Health Benefits Coordinator who will work with you to identify any possible programs. Completion of this form is no guarantee of benefits.