FORMS | ReliableRx

Please click on the link for each form below to access the PDF, which can then be downloaded and printed.

Reliable RX Intake Form
This form is required for all of our patients. It includes essential information about the patient's health and medication needs, enabling us to provide the best possible care and service.

Assignment of Benefits

This form allows us to bill the insurance company on your behalf (or the behalf of the patient receiving medication from us).

Medical Forms

Patient Rights and Responsibilities

This form outlines the essential components of care patients are entitled, and what is expected of them.

HIPPA Notification

This form is required by law to comply with the Administrative Safeguards of HIPAA Privacy, to secure and maintain the confidentiality of Protected Health Information, to maintain sensitive organizational information at Reliable Rx, and to prevent and detect inappropriate and illegal uses and disclosures.

Eligibility Requirements

This document provides all the information needed to determine if someone is eligible for our services.

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