Automatic Refill Authorization

By completing and submitting this form to Johnson Compounding and Wellness Center (JCWC),
am requesting enrollment in the JCWC Autofill Program1 . I hereby authorize JCWC 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 JCWC 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 JCWC 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)
MM slash DD slash YYYY
Authorization: I understand that my signature on this enrollment from constitutes my written authorization for JCWC 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.
MM slash DD slash YYYY