Prescription Fulfillment Consent and Acknowledgment Form for Partner Pharmacy

Purpose:
This consent form constitutes an authorization for Jack and Jill Health Inc. to transmit your prescription(s) to 1000223172 Ontario Inc. – ScaleRx (“the Partner Pharmacy”) for the purpose of facilitating the dispensing and fulfillment of your medication(s). Jack and Jill Health Inc. is committed to safeguarding your personal information in accordance with applicable statutory and regulatory requirements.

Authorization:
By completing this form, you expressly agree to the following terms:

1. Prescription Transmission:
   You hereby authorize Jack and Jill Health Inc. to disclose and transmit your prescription information, including but not limited to personal health information (“PHI”), to the Partner Pharmacy for the sole purpose of prescription processing and fulfillment.

2. Responsibilities of the Partner Pharmacy:
   You acknowledge and agree that the Partner Pharmacy shall handle your prescription and related information in accordance with its established policies and all applicable legal and regulatory requirements pertaining to the dispensing of medications.

3. Communication Authorization:
   You consent to being contacted by the Partner Pharmacy for any reason related to the fulfillment of your prescription. Such communications may include, but are not limited to, inquiries about insurance coverage, payment matters, or requests for additional information necessary to complete the dispensing process.

4. Data Privacy and Security:
   You acknowledge that your PHI will be securely transmitted and utilized solely for the purposes described herein. Jack and Jill Health Inc. and the Partner Pharmacy are obligated to protect your information in compliance with the Personal Information Protection and Electronic Documents Act (PIPEDA) and applicable provincial privacy legislation, including Ontario’s Personal Health Information Protection Act (PHIPA).

Voluntariness and Revocation:
This authorization is provided on a voluntary basis. You may revoke this consent at any time by submitting written notice to Jack and Jill Health Inc. Such revocation shall not apply retroactively to any disclosures or actions taken prior to the receipt of your written revocation.

By accepting this consent, I affirm that I have reviewed and understand the terms of this consent form. I further confirm that I have had the opportunity to ask questions and have received satisfactory explanations. I voluntarily provide my consent for Jack and Jill Health Inc. to transmit my prescription(s) to 1000223172 Ontario Inc. – ScaleRx.

 Please submit the form below if you would like your prescription(s) transferred out to another pharmacy.