Automatic Refill Authorization

By completing and submitting this form to Johnson Compounding and Wellness (JCW),
I am requesting enrollment in the JCW Autofill Program. I hereby authorize JCW to automatically refill my maintenance medications, charge my credit card the total amount due on a recurring basis as defined by my prescription’s day supply, and to contact my physician for a refill if no valid refills remain on my prescription. I understand that it is my responsibility to inform JCW if I wish to discontinue enrollment in the Autofill Program or if one of my medications is discontinued by my prescriber prior to the upcoming refill date. I acknowledge that failure to inform JCW of my intent to discontinue my enrollment in the Autofill Program or that my prescriber has discontinued one of my medications prior to the upcoming refill date may result in collection of the full cost of the medication associated with unwanted refill.
Patient Name(Required)
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Authorization: I understand that my signature on this enrollment from constitutes my written authorization for JCW to receive and use individually identifiable health information described above for the proper administration of the Autofill Program. This authorization shall remain in effect for the duration of my enrollment in the Autofill Program. I have the right to revoke this authorization anytime, except to the extent that my medical information already been used or disclosed in reliance on this authorization. However, because this information is essential to the administration of this program, my revocation of this authorization shall result in cancellation of my enrollment in the Autofill Program. We reserve the right to discontinue this service at any time.
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Some patients will be enrolled in the refill reminder program instead of automatic refill based on the requirements from their 3rd party insurance. The refill reminder program authorizes JCW representatives to call the phone number(s) listed in my profile to notify me my enrolled medication(s) are due to be refilled.