Welcome to the AdderallRx Intake Portal

This form is required before we can schedule your virtual consultation. You will:

1. Fill out our intake and consent form
2. Upload your medical records
3. Sign a HIPAA authorization form

At the end, we’ll confirm your submission and email you next steps.

Patient-Doctor Controlled Substance Contract

To ensure the safe and responsible use of controlled substances, I understand and agree to the following:

Prescription Agreement
I will only receive controlled substances prescribed by AdderallRX-affiliated providers. I will not seek similar medications from other physicians.
Pharmacy Use
I will only fill prescriptions at the contracted pharmacy associated with AdderallRX.com.
Medication Storage
I am responsible for safely storing all medication. Lost or stolen prescriptions will not be replaced without a valid police report.
Urine Drug Screens
I agree to participate in random or scheduled drug screenings to confirm compliance.
Pill Counts
I may be asked to complete random virtual pill counts on camera with 24-hour notice.
Refill Policy
I understand that early refill requests are denied unless a valid reason and documentation are provided.
Compliance
Failure to comply with this agreement may result in termination of care.

Please upload the last 30 days of records from your previous prescribing, diagnosing, or treating physician. These should show your diagnosis, treatment history, or prescription details.

I authorize AdderallRx and its medical team to access and use my health records as outlined above.

Authorization for Use or Disclosure of Health Information

I hereby authorize AdderallRX and its medical team to use or disclose my protected health information (PHI) as outlined below. This authorization allows the clinic to request, use, or share my health records for treatment, payment, and healthcare operations.

This includes (but is not limited to):

Medical history and clinical notes
Diagnoses and treatment plans
Medication and lab reports
Mental health or substance use information (if applicable)

Purpose of Disclosure:
Information may be shared to:

Coordinate care with other providers
Request or send medical records
Verify identity and eligibility
Comply with legal or insurance requirements

Your Rights:

I may revoke this authorization at any time by submitting a written request to AdderallRX.
Revoking this does not affect actions already taken based on prior consent.
Refusing to sign may limit the ability to provide or coordinate care.
Once disclosed, information may no longer be protected by HIPAA.

Expiration:
This authorization is valid for one year from the date signed or until revoked in writing.

By signing, I acknowledge and agree to the use or disclosure of my health information as stated above.

Please read each term carefully and check the boxes to confirm your understanding and agreement. You must sign at the bottom of the form.

Thank you for completing your intake and onboarding!

We are currently entering your information into our EHR system. Once that is complete, we will email you with available time slots for your virtual consultation with one of our licensed physicians.

If any additional documents are required, our team will reach out.