By submitting this form, I agree to be contacted by a provider at JNS Health Solutions. I understand that as a Medicaid patient, I can obtain my supplies, including free condoms, from any qualified provider of my choice. However, I voluntarily consent to JNS Health Solutions, which operates an in-house DME, to contact me regarding my care. This includes dispensing and delivering condoms monthly as prescribed until I cancel, submitting claims to Medicaid on my behalf, and I acknowledge receipt of the HIPAA Notice of Privacy Practices. Additionally, I am aware of the Nebraska Condom Program that supports my access to necessary resources, including STD checks.