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.
- Email: firstname.lastname@example.org
- Fax: 877-757-9935
- Mailing Address: 199 Park Rd Ext Middlebury, CT 06762
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.