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Patient Paperwork

Patient Paperwork

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Patient Right Handout PDF Form
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    Patient Information

    Last Name

    First Name

    SS Number

    Date of Birth

    Home Number

    Cell Number

    Email Address

    Upload Photo ID

    *CANNOT SHIP TO PO BOXES, PLEASE MAKE SURE THIS IS A PHYSICAL ADDRESS

    Address

    City

    State

    Zip Code

    Emergency Contacts

    Contact Name

    Contact Number

    Contact Name 2

    Contact Number 2

    *IF YOU ARE IN THE CARE OF A HOME HEALTH AGENCY PLEASE COMPLETE THIS SECTION

    Referring Agency

    Contact Person

    Phone Number

    Fax Number

    Person Taking Referral

    Date Received

    Medical Information

    Ordering Physician Name

    Specialty

    Address

    City

    State

    Zip Code

    Phone Number

    Fax Number

    Primary Physician Name

    Address

    City

    State

    Zip Code

    Phone Number

    Fax Number

    Insurance Information

    Primary Insurance Company

    Address

    City

    State

    Zip Code

    Phone Number

    Fax Number

    Member ID

    Group Number

    Upload Primary Insurance Card (Front & Back)

    Front (Maximum File Size: 5mb)

    Back (Maximum File Size: 5mb)

    Secondary Insurance Company

    Address

    City

    State

    Zip Code

    Phone Number

    Fax Number

    Member ID

    Group Number

    Upload Secondary Insurance Card (Front & Back)

    Front (Maximum File Size: 5mb)

    Back (Maximum File Size: 5mb)

    Authorization & Consent

    Authorization/Consent for Care/Service: I have been informed of the home care options available to me and of the selection of providers from which I may choose. I authorize Lifecare Technology under the direction of the prescribing physician, to provide durable medical equipment, supplies and services as prescribed by my physician.

    Assignment of Benefits/Authorization for Payment: I hereby assign all benefits and payments to be made directly Lifecare Technology, for any durable medical equipment, supplies and services furnished to me in conjunction with my home care. I authorize Lifecare Technology to seek such benefits and payments on my behalf. It is understood that, as a courtesy, Lifecare Technology will bill Medicare/Medicaid or other federally funded sources and other payers and insurer(s) providing coverage. I understand that I am responsible for providing all necessary information and for making sure all certification and enrollment requirements are fulfilled.

    Release of Information: I hereby request and authorize Lifecare Technology, the prescribing physician, hospital, and any other holder of information relevant to service, to release information upon request to Lifecare Technology, any payer source, physician, or any other medical personnel or agency involved with service.

    Financial Responsibility: I understand and agree that I am responsible for the payment of any and all sums that may become due for the services provided. These sums include deductibles, co-payments, out-of-pocket requirements, and non-covered services.

    I acknowledge that I have been advised of my financial responsibilities to Lifecare Technology.

    Returned Goods: I understand that, due to Federal and State Regulations, ancillary items prescribed for home health care cannot be redispensed. Therefore, ancillary items cannot be returned for credit.

    Patient Handouts: I acknowledge that I have received a copy of the Patient Handouts which contains Patient Rights and Responsibilities, Supplier Standards, Home Safety Information, HIPAA Privacy Standards, Emergency Planning, Advance Directive Information and Grievance / Complaint Reporting.

    Complaint Reporting: I acknowledge that I have been informed of the procedure to report a grievance should I become dissatisfied with any portion of my home care experience.

    Patient Name

    Date

    Representative Name

    Date

    Upload Your Signature

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