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Patient Form Downloads​

After completing the form(s), you may fax, mail, or email the form(s) to us. If you choose to email the form(s), please note that J&L® Medical cannot assure the security of your email transmission so there is a risk that your protected health information (PHI) could be read, viewed or otherwise accessed by a third party. If you continue to send this email, you will have assumed this risk to email the form(s) to us. There is no requirement to send the form(s) via email.


Patient Agreement and Consent Form

This form allows us to provide you with services and bill your insurance company if applicable. It also provides you with your rights and responsibilities as a customer for J&L® Medical Services.


Disclosure Consent Form

To better protect your privacy, your health information and account information will only be discussed with those you choose to receive such information within the Disclosure Consent form. 


Charge Authorization Form

This document allows us to bill your financial institution for costs not covered by your insurance.


Financial Hardship Form

Complete the attached form if you need to apply for financial hardship as it relates to services you are wishing to receive from J&L® Medical Services.


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Still Can't Find What You're Looking For?​

Here are a few of our most requested links and resources.​

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