Enrollment Forms

JRA HEALTH INFUSION CARE

Get Started with JRA Health – Enrollment Forms

We aim to make the enrollment process as seamless as possible. Whether you’re a patient, provider, or caregiver, completing the necessary forms is the first step to receiving expert, personalized infusion therapy at home.

To ensure timely and accurate care, we’ve provided easy access to all the forms needed to begin your infusion therapy journey. Our team is available to assist you throughout the process, ensuring that all documents are submitted properly and your care can begin without delay.

Enrollment Forms for Patients

If you’re a patient seeking infusion therapy with JRA Health, the following forms are required to begin your care. These forms help us gather important information about your medical history, current prescriptions, and insurance details, so we can create a personalized treatment plan that meets your needs.

Patient Information Form

This form collects your personal and medical information, including your health history, current medications, and contact details.

Download

Insurance Authorization Form

Complete this form to provide us with your insurance information, so we can begin the approval process for your infusion therapy.

Download

Consent to Treat Form

By signing this form, you give JRA Health permission to administer infusion therapies and work with your healthcare provider to manage your care.

Download

Once these forms are completed and submitted, our team will handle the rest—coordinating with your healthcare provider and insurance company to ensure your therapy begins promptly.

Forms for Providers

For prescribers and healthcare professionals looking to refer patients to JRA Health, we provide easy-to-use forms that allow you to quickly submit patient information and treatment plans. We handle all the details, ensuring that your patients receive the infusion therapies they need, without delay.

Referral Form

Submit this form with the patient's information and prescribed therapy. Our team will take it from there, managing insurance approvals, medication delivery, and coordination with nursing teams.

Download

Prescription Form

Complete this form with the required infusion medication and dosage details, so we can ensure timely and accurate administration of the therapy.

Download

We work closely with providers to make sure that every patient’s treatment is tailored to their unique medical needs, ensuring seamless coordination from referral to therapy completion.

Forms for Caregivers

Caregivers play a vital role in the health and well-being of patients receiving infusion therapy. To ensure that you have all the information and resources needed to support your loved one, JRA Health provides forms that allow you to participate in the care process.

Caregiver Consent Form

If you will be involved in the administration of the patient’s infusion therapy, please complete this form to provide us with your contact information and consent to participate in the treatment process.

Download

Caregiver Information Form

Share important details about your role as a caregiver, so we can ensure you have all the resources and support you need throughout the treatment process.

Download

How to Submit Your Forms

To begin receiving care with JRA Health, simply download and complete the relevant forms from the links below. Once completed, forms can be submitted by:

Email

Scan and email your completed forms to vasb@wenurnygu.pbz.

Fax

Fax your completed forms to [insert fax number].

Mail

Send your completed forms to our office at:

6925 SE US Highway 301, Hawthorne, FL 32640

If you have any questions or need assistance with the forms, please don’t hesitate to reach out to our team. We are here to help ensure that every step of your enrollment process is smooth and efficient.

CONTACT US

Begin Your Journey to Better Care

We’re committed to providing personalized, high-quality infusion therapies to patients in the comfort of their homes. Completing these forms is the first step toward receiving the care you need. Once we receive your forms, our team will handle the rest—coordinating with your healthcare provider and ensuring that your treatments are delivered on time.