Medical Equipment and Supplies
Patient Intake Form
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Type of Medical Equipment ordered by your Provider
Please Select
Diabetic Footwear (A5500,A5512)
Standard Walker (E0143)
Standard wheelchair (K0001)
Lightweight wheelchair (K0003)
Rollator Walker with seat (E0143, E0156)
Nebulizer (E0570)
Compression Stockings (A6530)
Standard wheelchair (K0001)
Bedside Commode (E0163)
Orthopedic Back Brace (L0627)
Orthopedic Knee Brace (L1852)
Orthopedic Wrist Brace (L3809)
Crutches (E0114)
Walking Boot (L4387)
Seat Lift (E0627)
Other
Provider's Office Name and Location
Please enter the name of your Provider
Insurance Attestation
*
Check this box attesting to completing the medical insurance information below. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for your medical equipment and supplies
Medical Insurance Company Name
*
ID #
*
Group #
Upload a copy of your insurance card
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of
Consent
I acknowledge that I have chosen to use this particular device and Citizens Pharmacy. I authorize my healthcare provider and Citizens Pharmacy to release any of my medical information required by insurer to process the claim. I permit a copy of this authorization to be valid as the original. All costs of the device and/or supplies that are not paid for by my insurance company will become my responsibility. I shall be liable for all costs of collection. I hereby acknowledge that I have received a copy of the Patient Rights and Responsibilities and Privacy Notice on the reverse side of this form. I consent to receive Pharmacy Communications by Phone Call, Text Message and Email. I confirm the information provided by me in applying for payment under Medicare and/or any other insurance is true and correct. I request services/products/equipment furnished to me. I authorize any holder of health/medical or related information about me is released to Citizens Pharmacy agents for the purpose of determining benefits for related services/equipment/products, and applying for payment. I authorize Citizens Pharmacy to release to CMS, CMS Intermediaries, commercial insurance, accrediting bodies, state/federal entities as needed for insurance claims payments or quality assessment purposes. I have received all of the aforementioned documentation, and, I have been instructed in the safe and proper use of the aforementioned medical equipment and will use at home as taught.
HIPAA Privacy Information and Medical Records
(1) I have acknowledged that I have received the providers Notice of Privacy Practices which may be provided at my request. (2) For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct. (3) I authorize the release of all records to act on this request and I request that the payment of benefits be made on my behalf.
Acknowledgement
*
I consent to the above and acknowledge the HIPAA Privacy Information & Medical Records
Signature
*
Submit
Administration
For Pharmacy Use Only
Upload Order and other relevant patient files
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Completed By
Samir Shah
Taylor Bourdage
Ashley Brown
Artisha Davis
Jessica Jahuey
Jasmine Costin
Justin Moore
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