Insurance & Medical Equipment Intake
Please provide your insurance information and medical equipment or supply needs. Our team will securely review your information and contact you regarding the next steps.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
Phone
Email
Street Address
*
City
*
State
*
ZIP Code
*
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Insurance Information
Primary Insurance Provider
*
Member/Policy ID
*
Group Number
Policyholder Name
First Name
Last Name
Relationship to Policyholder
Self
Spouse
Parent
Other
Does the patient have secondary insurance?
*
Yes
No
Secondary Insurance Provider
Secondary Member/Policy ID
Secondary Group Number
Front of Insurance Card
Upload Front of Insurance Card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Back of Insurance Card
Upload Back of Insurance Card
Upload a File
Drag and drop files here
Choose a file
Cancel
of
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Equipment or Supplies Needed
What medical equipment or supplies do you need?
*
Mobility Equipment
Bathroom Safety Equipment
Orthopedic/Support Equipment
Respiratory Equipment/Supplies
Incontinence Supplies
Diabetes Supplies
Other
Please describe the equipment or supplies you need.
Is this equipment or supply request for you?
*
Yes
No
Patient Name
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Patient
Please Select
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Physician / Provider Information
Referring Physician/Provider Name
*
First Name
Last Name
Practice/Facility Name
Physician/Provider Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician/Provider Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Physician/Provider Email Address
example@example.com
Do you currently have a prescription or physician order for this equipment?
*
Yes
No
Not Sure
Upload Prescription/Physician Order
Upload a File
Drag and drop files here
Choose a file
Cancel
of
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Acknowledgment & Submission
Acknowledgment
Confirmation and Authorization
*
I confirm that the information provided is accurate to the best of my knowledge and authorize Mercy Medical Supplies to review this request and contact me, my insurance provider, and/or my referring healthcare provider as needed. I understand that submission does not guarantee insurance eligibility, coverage, authorization, or payment.
Patient / Authorized Representative Name
*
First Name
Last Name
Relationship to Patient
*
Please Select
Self
Spouse
Parent
Legal Guardian
Caregiver
Other
Electronic Signature
*
Submit
Submit
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