DME INTAKE FORM

FIRST NAME*

LAST NAME*

STREET ADDRESS*

IS THERE AN APARTMENT NUMBER?

CITY*

STATE*

ZIP CODE*

GENDER*

AGE*

MARITAL STATUS*

CAN YOU CONFIRM YOUR DOB?*

MonthDayYear

PRIMARY PHONE NUMBER*

Area CodePhone Number

SECONDARY PHONE NUMBER

Area CodePhone Number

EMAIL ADDRESS

PRIMARY INSURANCE*

PRIMARY INSURANCE ID OR CLAIM # FROM HEALTH CARD*

MUST BE THEIR MEDICAL INSURANCE

RX BIN NUMBER*

ALWAYS 6 DIGITS

GROUP NUMBER*

CLAIMS*

TURN CARD OVER (IF NO NAME THEN GOOGLE IT)

WHAT IS THE CUSTOMER SERVICE PHONE NUMBER ON YOUR HEALTH CARD*

DO YOU HAVE MEDICARE OR MEDICAID AT ALL?*

IF MEDICAID, DEAL IS DEAD

WHERE ARE YOUR AREAS OF PAIN?*

TENS MACHINE*

BACK BRACE*

POSTURE PUMP*

KNEE BRACE*

ANKLE BRACE*

WRIST BRACE*

SHOULDER BRACE*

ELBOW BRACE*

SHIRT SIZE (IF THEY ARE GETTING BRACES)*

APPROVED BIN?*

PAIN CREAM*

INFLAMMATION PILL*

SCAR CREAM*

SKIN ALLERGY CREAM*

HERE IS WHERE YOU WILL ASK THEM IF THEY ARE INTERESTED IN THE CANCER TESTING. REITERATE IT WILL ONLY BE A COUPLE MORE QUESTIONS.

HAVE YOU OR ANYONE IN YOUR FAMILY EVER BEEN DIAGNOSED WITH ANY TYPE OF CANCER?*

MATERNAL OR PATERNAL?*

CANCER TYPE*

OTHER (CANCER TYPE)

ETHNICITY*

BEST TIME TO CALL*

AGENT NAME*

OFFICE*