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*

MaleFemale
Patient Phone Number*

Country CodeArea CodePhone Number
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)

602A / Physician’s ReportPOLST (Physician Orders for Life-Sustaining Treatment)Medication Reconciliation / Prescription RefillDoctor VisitTuberculosis (TB) Clearance X-Ray (Results within 24–48 hours)Tuberculosis (TB) Clearance QuantiFERON (QFT) Blood Test (Results within 3–7 days)COVID-19 TestingOther
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

Morning (8 AM – 12 PM)Afternoon (12 PM – 4 PM)Evening (4 PM – 8 PM)Flexible / Anytime
Who do we bill *
Name of Legal Representative

First NameMiddle NameLast Name
Phone Number of Legal Representative
Please enter your phone number, including area code
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 code
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 code
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 code
Email of Community Representative
example@example.com
Community Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload Nursing Assessment (optional)

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

Cancelof
Please upload Physician Report (602A) and other documents to be completed by a doctor

Cancelof
Please upload Medical History (TB clearance, optional)

Cancelof
Please upload the Medication List

Cancelof
Who should we thank for the referral
Please upload the Power of Attorney if applicable

Cancelof
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