WeCare Intake Form

WeCare Client Intake

All the information needed to initiate your benefits.
Name

First NameLast Name
SOCIAL SECURITY NUMBER
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Essential Items: Please upload Photo ID and Insurance Card

Cancelof
Allergies?
Medications (separated by a comma ",")
Which type of PrEP

TRUVADADESCOVYN/A
Insurance Type

MedicaidMedicare Part DMarketplacePrivate InsuranceOther
Name as it appears on insurance card

First NameLast Name
Insurance provider
Insurance ID #
BIN #
Group #
PCN #
Pharmacy Fulfillment Preference

DeliveryPickup
Patient Choice Authorization

WeCare LF, Inc. has a contract pharmacy agreement with various local pharmacies to provide pharmacy services to all of our patients. I've been told that I can choose to use any pharmacy to fill my prescriptions. This form will be applicable for all future prescriptions dispensed through WeCare LF, Inc.
Authorization

I choose WeCare LF, Inc. to fill my prescriptions.I do NOT choose WeCare LF, Inc. to fill my prescriptions.
Signature

Clear
Medical Release Authorization

I, {name}, hereby grant permission for you to release confidential health information about me, by releasing a copy of my medical record, or a summary or narrative of my protected health information, to the physician / person / facility /entity.
Signature

Clear
Should be Empty:

WeCare Client Intake