Vital Health Services – Patient Product Intake & Coverage Review

Vital Health Services – Patient Product Intake & Coverage Review

Complete this secure intake to share eligibility, insurance, and product needs, and electronically consent to verification and record requests.
Patient & Representative Information
Person Completing This Form

Other
Patient Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex as Listed with Insurer

Other
Service Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address if Different

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Caregiver / Representative Contact Name

First NameMiddle NameLast Name
Preferred Language
Product Category
Insurance & Coverage Review
Primary Insurance Name
Member ID
Group Number
Plan Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insurance Name
Upload Insurance Card Front and Back

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Authorization and Coverage Review Permissions

Other
Current Supplier
Urgency

Other
Prescriber & Clinical Basics
Prescribing clinician name

First NameLast Name
Practice name
Practice phone
Please enter a valid phone number.Format: (000) 000-0000.
Practice fax
Primary diagnosis or condition
Height (inches)
Weight (lbs)
Urology Supplies
Catheter type needed/currently used
Catheter French size
Catheter length
Quantity per day
Primary condition/indication
Ability to self-catheterize
Reason coude catheter is needed

Other clinician-documented reason
Sterile kit needed
Current product/manufacturer
Last shipment date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Skin sensitivity or latex allergy
Upload prescription or clinical notes

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Incontinence Supplies
Coverage Note: This form is secure. Do not use ordinary email to send PHI. Submission does not guarantee coverage or delivery. For emergencies, call 911 or contact the treating clinician.

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Daytime size
Nighttime size
Waist/hip measurement
Quantity per day
Supplies Requested

Other
Pediatric or Adult
Incontinence Type
Mobility / Toileting Status
Underlying Diagnosis
Caregiver Assistance

Other
Skin Breakdown Present
Current Brand
Dietitian involved
Swallow evaluation completed
Last shipment date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has regular food or a modified diet been tried?
Why is it insufficient?
Last Shipment
Upload Prescription / Records (Optional)

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Supply Details
Nutrition Supplies
Nutrition delivery method

Other
Product/formula currently prescribed
Flavor
Calories per container
Containers per day
Feeding route
Delivery method

Other
Diagnosis causing impaired nutrition
Allergies or intolerances
Height (inches)
Weight (lbs)
Recent weight change
Percentage of nutrition from formula

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

80 is 0%, 100 is 100%
Able to eat regular food

Other
Requested supplies

Other
Current product or NDC, if known
Upload supporting documents

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General DME
Requested DME Items

Other
Request Type
Diagnosis and functional limitation
Where will the item be used?
Ability to move inside the home
Difficulty with activities of daily living

Other
History of falls
Current equipment in use
Age of current equipment
Patient height
Patient weight
Home access limitations

Other
Expected discharge date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Clinician recommendation
Product specifics by selected item
Upload prescription or clinical notes

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Consent, Checklist & Signature
Consent acknowledgements

Other
Upload checklist

Other
Acknowledgements and attestations

Other
Typed patient or representative name

First NameMiddle NameLast Name
Relationship to patient
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Document upload

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Should be Empty:

Vital Health Services – Patient Product Intake & Coverage Review

Patient & Representative Information

Insurance & Coverage Review

Prescriber & Clinical Basics

Urology Supplies

Incontinence Supplies

Nutrition Supplies

General DME

Consent, Checklist & Signature