Patient Consultation Intake Form
All information entered is PHI-HIPAA protected and compliant.
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Contact Email
*
example@example.com
Contact Phone Number
*
Format: (000) 000-0000.
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is this for?
*
Myself
Spouse
Parent
Child
Other
Patient Insurance Provider
*
Insurance Type
*
Please Select
Traditional Medicare
Medicare Advantage Plan
Dual Medicare-Medicaid
Employer Insurance
Marketplace Plan
Uninsured
Not Sure
Insurance Card (Front)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Card (Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Concerns (check all that apply)
*
ALL
Understanding benefits/coverage
Understanding bills
Understanding denied/delayed services
Help appealing a bill or denial
Patient to Provider advocacy
Patient to Insurance advocacy
Billing from multiple providers
Billing for multiple family members
Other
In your own words, briefly describe your needs.
*
How urgent are your needs?
*
Please Select
Low (I'd like to connect in 2-4 weeks)
Moderate (I'm confused but stable)
High (I have past due or final notices)
Critical (I'm in collections/financial hardship)
I understand this is a consulting service. Maison Dexara Inc. does not provide medical or legal advice and/or representation.
*
Yes
No
I understand the consultation is based on documents provided by the patient. Any additional documents provided after submission may change outcomes.
*
Yes
No
I understand that Maison Dexara’s patient support services are for billing and insurance education purposes only and do not guarantee claim payment, denial reversal, coverage approval, balance reduction, refund eligibility, or any specific outcome.
*
Yes
No
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: