New Patient Packet Acknowledgment and Contact Authorization

New Patient Packet Acknowledgment

By submitting this form, I acknowledge receipt of the AdaptHealth Patient Care Solutions (AHPCS) New Patient Packet which includes the following: Contact Information, Patient Freedom of Provider Statement, Medicare Supplier Standards, Return Policy, Warranty, Notice of Privacy Practices, AHPCS Customer Rights and Responsibilities, Civil Rights Notices, Product Education, and Be Red Cross Ready.

Patient ID/ Account #

Patient ID / Account #

Full Name

Patient First NamePatient Last Name

Date of Birth

Patient's Birth Date

Primary Caregiver/ Name

First NameLast Name

Relationship

Relationship to Patient

Phone Number

Patient PhoneFormat: (000) 000-0000.

Signature

Date

Today's date

If you are the legal representative of the individual listed above, please check the basis for your authority:

You can skip this section if you are not or do not have a legal guardian.

Other (please specify)

File Upload

Legal Representative Name

First NameLast Name

Legal Representative Signature

Date

Today's date

Contact Authorization
AdaptHealth Patient Care Solutions (“AHPCS”), along with its parent company, subsidiaries, and affiliated entities (collectively, “AdaptHealth”), may periodically send information about products, services, programs, promotions, newsletters, and other marketing or educational campaigns that may be of interest to you.

This authorization is voluntary and not required as a condition of receiving products or services from AHPCS.

Please review and indicate your preferences below:

I authorize AdaptHealth and its affiliates to contact me for marketing, promotional, and informational purposes, including newsletters and sample campaigns, using the communication methods I select below:

Reorder Communications

Email

Text

Phone

Marketing Communications

Email

Text

Phone

Email marketing:

Email communication:

Text message (SMS) marketing:

Text message (SMS) communication:

Phone communication (including automated or prerecorded messages, where permitted by law):

Phone marketing:

Primary Phone

Format: (000) 000-0000.

Telephone Type

Alternate Number

Alternate phone of patient or caregiverFormat: (000) 000-0000.

Telephone Type

E-mail

example@example.com

Name

First NameLast Name

Important Information

I understand that these communications may include advertisements or promotional content about AdaptHealth products and services.
I understand that my consent is not required to receive treatment, products, or services.
I understand that I may opt out at any time by:
Clicking the “unsubscribe” link in emails
Replying “STOP” to text messages
Contacting AHPCS customer service
I understand that message and data rates may apply for text messages.
I acknowledge that my information will be used in accordance with AdaptHealth’s Notice of Privacy Practices.

Authorization

By signing below, I confirm that:

I have read and understand this Marketing Communications Consent Authorization
I voluntarily agree to receive marketing communications as indicated above

Signature

Date

Today's date

AdaptHealth Patient Care Solutions
PO Box 1135, Moon Township, PA 15108-9939
T 855.404.6PCS (6727)
F 800.749.0711
PCSinfo@adapthealth.com

¹ Standard text messaging rate may apply.