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.

Parent of MinorPower of Attorney (attach copy)Guardianship Order (attach copy)Other (please specify)

File Upload

Legal Representative Name

First NameLast Name

Legal Representative Signature

Date

Today's date

Contact Authorization
You are receiving this authorization request because AdaptHealth Patient Care Solutions (AHPCS) uses prerecorded messages, text messaging¹, and electronic correspondence to remind our customers that it may be time for a supply reorder or to deliver other important information. We would like your permission to use these types of messaging. You are not required to sign this agreement in order to continue to receive products from AHPCS.

Please confirm your authorization for each of the following options by checking “yes” or “no”. If you choose “yes”, please list the phone number and/or email address that you authorize AHPCS to contact through its automated technology.

I understand that AHPCS provides me with medically necessary products and may need to contact me regarding my order or to provide other necessary information regarding my products. I authorize AHPCS to contact me via the communication option(s) selected below.

I agree to be contacted by email*

I agree to be contacted by text messaging*

I agree to be contacted by phone*

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

Signature*

Date*

Today's date

To acknowledge receipt and grant permission, please submit this form by clicking the submit button below.

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.