Find patient and facility PDFs. Contact the pharmacy to confirm how completed documents should be transmitted securely.
Consent for use and disclosure of protected health information for treatment, services, payment, and health care operations.
Collects patient, emergency contact, facility, prescriber, insurance, and financially responsible party details.
Internal return and destruction documentation used when medication return review is needed.
General patient education material about unwanted or expired medication disposal options.
Spanish-language version of the disposal brochure for broader patient access.
The On Call, LLC document explains how to request emergency after-hours help and what information should be prepared before the call.
Select the form that matches your need: privacy consent, patient intake, after-hours guidance, or return documentation.
Most workflows move faster when the patient, prescriber, medication, and contact details are ready before submission or follow-up.
Call (408) 847-6160 or use the contact page if you need help identifying which form applies to your request.
The Identification and Guarantor Information Sheet contains fields for a Social Security number, payment-card number, and card security code (CVV), in addition to medical and insurance information. This makes it highly sensitive. Do not send a completed form by ordinary email, enter details into this website's search box, or upload it through an unverified service. Before using it, call (408) 847-6160 to confirm which information is truly necessary and obtain an approved secure submission method.
The HIPAA Client Form describes patient consent for use and disclosure of protected health information, but is not a replacement for the pharmacy's full, current Notice of Privacy Practices. Request that notice directly from the pharmacy before signing.
For disposal, the English and Spanish MED-Project educational brochures describe kiosks, mail-back programs, and take-back events. Visit MED-Project to confirm current participating locations and eligible medicines. These are disposal resources, not refunds or purchase returns.
