Active Life Form

1

Are you a new patient with Active Life?* This field is required.

YESNO

2

How can we help you?* This field is required.

Reorder same items as before

New prescription and/or update information

3

Welcome back to Active Life! Before starting, please review the following information by clicking each link below. There may have been some changes since the last time you reviewed these. You will be asked for an acknowledgment e-signature. You may also email or call us to request a paper copy.

HIPAA Policies
Office Policies
Medicare Supplier Standards (if applicable)
Assignment of Benefits (if applicable)

4

Welcome to Active Life! Before starting, please review the following information by clicking each link below. You will be asked for an acknowledgment e-signature. You may also email or call us to request a paper copy.

HIPAA Policies
Office Policies
Medicare Supplier Standards (if applicable)
Assignment of Benefits (if applicable)

5

If you would you like to add a family member or friend as your HIPAA contact, please do so below. This person will be authorized to receive information regarding your Active Life services, and will be added as your emergency contact.

Full Name of Authorized Individual

Relationship to Patient

Phone Number of Authorized Individual

6

I agree that I have been provided and reviewed the HIPAA Policies, Medicare Supplier Standards, Assignment of Benefits, and Office Policies. The information that I will provide in the following form is accurate.* This field is required.Use finger or mouse to sign below.

ClearSignature of Patient or Parent/Guardian

7

What is the patient's name?* This field is required.

First Name

Last Name

8

What is the patient's date of birth?* This field is required.

9

Current Date

Date

10

Patient's Age

11

What is the patient's sex?* This field is required.

12

The patient is under age 18. Please enter primary parent/guardian name and relation to patient.* This field is required.

Parent/Guardian Full Name

Relationship to Patient

13

If you are able to upload an image of the parent/guardian's photo ID, please do so here. Optional

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

14

If you are able to upload an image of your photo ID, please do so here.Optional

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

Has any of your contact information changed since we last worked with you?* This field is required.If you would like an email receipt of your form submission today, select "YES" then enter your email address.

YESNO

16

Please provide your email address and phone number.* This field is required.

Email address for appointment reminders and receipts

Phone number for contacting you during the day

17

Please provide a current mailing address.* This field is required.If your specific service requires that items are shipped, this address needs to be able to receive packages.

Street Address

Street Address Line 2

City

State

Zip Code

Country

18

Please be aware that insurance coverage is never a guarantee of payment. Before processing your order, we will verify your benefits and give you an estimate for your coinsurance. Financial responsibility is based on the insurer's review of your claim.* This field is required.

I have read the above disclaimer.

19

Would you like us to submit the bill to your health insurance?* This field is required.(If we do not have your insurance information, your care will be self-pay. You can update this by calling Active Life.)

YESNO - I will be self-pay

20

Has your insurance information changed since we last saw you?* This field is required.

YESNO

21

Please enter all relevant insurance information below.If unsure, type "I don't know" in the required spaces. We will get the required information during a follow-up call.

Primary Carrier (Required)

Secondary Carrier

Primary Member ID (Required)

Secondary Member ID

Primary Group Number (Optional)

Secondary Group Number

22

If you are able to upload images of the FRONT and BACK of your insurance card, please do so here.Optional

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

23

Were you referred to Active Life by a healthcare professional?* This field is required.

YESNO

24

Which healthcare professional referred you?* This field is required.If unsure, type "I don't know". Please locate your doctor's information before your appointment.

Physician Name

25

Do you have a prescription?* This field is required.

YESNO

26

If you are able to upload an image of your prescription, please do so here.Optional

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

27

Select the PRIMARY device type you are being seen for. Comment about additional items at the end.* This field is required.

Prosthetics (Artificial Limbs)

Orthotics (Braces)

Compression

Diabetic Shoes

Mastectomy

28

Select the PRIMARY device type your child is being seen for. Comment about additional items at the end.* This field is required.

Prosthetics

Cranial Remolding Helmet

Compression

Scoliosis (Curved Spine) Brace

Leg Bracing (SMOs/AFOs/KAFOs)

Arm/Hand Bracing

Pectus (Chest Wall Deformity)

Orthopedic Shoes/Inserts

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Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.