Intake

Protected Health Information (PHI): Ensuring that our patients' information is safe, secure is one of our top priorities. This form is HIPAA compliant and SHA-256 with RSA Encrypted.

hereby authorize the clinic’s staff on duty to act on my behalf to accept medication delivery from the clinic’s dispensing physician and deliver my medications and refills to me as prescribed by my physician. I understand that the delivery of such medications can be picked up at the clinic or mailed to my provided address every week (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

No Guarantee of Services

We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up process and physician’s examination. At the physician’s discretion only, you will be provided medications and/or services during your program at Illinois Alternative Medicine.

Patient Authorization for Delivery of Medications

Draw your E-Signature.