RCFE Service J1

Welcome to the Doctor2me

Thank You For Choosing Us As Your Trusted Healthcare Provider.
Please complete this intake form with as much detail as possible so we can ensure prompt, personalized service. If you need assistance, contact us at: intake@doctor2me.com or 866-602-6022.
Patient Full (Legal) Name

First NameMiddle Name (not required)Last Name
Patient Date of Birth

MonthDayYear
Sex Assigned at Birth
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email
example@example.com
Service Address
Provide The Address Where The Visit Or Service Will Take Place

Street Address

Appt #

CityState

Zip Code
Entry Instructions For In-home Visits Only
What Is Your Relationship To The Patient?
Can The Patient Make Their Own Healthcare Decisions?
Type Of Visit and/or Service Requested (Select All That Apply)
Please specify Service Requested
Please Provide a Date by Which the Assessment and/or Service Need to be Completed

MonthDayYear
Preferred Time Window For Visit
Who do we bill
Name of Legal Representative

First NameMiddle NameLast Name
Phone Number of Legal Representative
Please enter your phone number, including area codeFormat: (000) 000-0000.
Email of Legal Representative
example@example.com
Name of Family Member/Caregiver

First NameMiddle NameLast Name
Phone Number of Family Member/Caregiver
Please enter phone number, including area codeFormat: (000) 000-0000.
Email of Family Member/Caregiver
example@example.com
Name of Billing Contact

First NameLast Name
Phone Number of Billing Contact
Please enter phone number, including area codeFormat: (000) 000-0000.
Email of Billing Contact
example@example.com
Name of the Community
Name of Community Representative

First NameMiddle NameLast Name
Phone Number of Community Representative
Please enter phone number, including area codeFormat: (000) 000-0000.
Email of Community Representative
example@example.com
Community Address

Street Address

Street Address Line 2

CityState

Zip Code
Please Upload Nursing Assessment (Optional)

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Please Upload the Patient's ID with pic (e.g., DL, ID, ?)

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Please Upload Physician Report (602A) and Other Documents to be Completed by a Doctor

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Please Upload Medical History (TB Clearance, Optional)

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Please Upload the Medication List

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Who Should We Thank for the Referral
Please Upload the Power of Attorney if Applicable

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AS LEGAL REP I agree to Doctor2me's Terms of Service, Arbitration Agreement, Consent to Treat, Privacy Policy, and Cancellation Policy located at https://www.doctor2me.com/terms
I agree to Doctor2me's Terms of Service, Arbitration Agreement, Consent to Treat, Privacy Policy, and Cancellation Policy located at https://www.doctor2me.com/terms
Should be Empty:

Welcome to the Doctor2me