Patient Intake and Consent Form

Thank you {{patient_name_}} for submitting your Patient Intake
and Consent Form information to HomeMD Health.

We will contact you within 1 business day.

https://www.homemdhealth.com/wp-content/plugins/nex-forms

true

https://bestbuy.com

message

https://www.homemdhealth.com/wp-admin/admin-ajax.php

https://www.homemdhealth.com/patient-intake-and-consent-form

yes

fadeIn

fadeOut

Patient Intake and Consent Form

Please complete our online Patient Demographic Form to register yourself or your loved one for service with HomeMD Housecall Services. Once we receive your intake information along with the signed consent form, a referral specialist will contact you shortly thereafter (usually the same day) to coordinate for the first appointment with our provider staff.

Referral By :

Patient Name *

Patient Date Of Birth *

Primary Phone

Primary Phone Type

Secondary Phone

Secondary Phone Type

Best time to call *

8AM - 11AM

11AM - 1PM

1PM - 3PM

3PM - 5PM

Best way to contact you *

By Phone

By Email

SSN or Medicare Card #

*Gender

Marital Status

Patients Address

*Street Address

*Apt. or Suite

*City

*State

*Zip Code

Billing Address (if different than patients primary address)

Street Address

Apt. or Suite

City

State

Zip Code

Patient lives in a . . .

Facility Panel Area

Patient Residence Info

Patient Residence Name ( if applicable )

Patient Residence Street Address

Patient Residence Suite #

City ( of Patient Residence )

State ( of Patient Residence )

Zip Code ( of Patient Residence )

Primary Insurance Information :

*Primary Plan Type

Other Primary Insurance Plan type

Primary Member ID # *

Primary Group #

Plan ( of Primary Insurance ) *

Secondary Insurance Information :

Secondary Plan Type

Other Secondary Insurance Plan type

Secondary Member ID #

Secondary Group #

Plan ( of Secondary Insurance )

Submit Image of Insurance Card ( front )Maximum 3MB file size ( jpg, jpeg, png, pdf )

jpg jpeg png pdf

Submit Image of Insurance Card ( back )Maximum 3MB file size ( jpg, jpeg, png, pdf )

jpg jpeg png pdf

Emergency / Health Care Advocate

Does the Patient Have an Advocate ? *

Yes

No. Does not have an advocate

Relationship to the Patient *

Name of Advocate / Emergency Contact

Advocate Cell Number

Advocate Home Number

Advocate Email

Primary Care Information

( So that we can coordinate care and/or retrieve records, if we are assuming primary care )

Current or Former PCPs Name

Current or Former PCPs Phone #

Current or Former PCPs Fax #

Yes

Please have HomeMD Housecall Services assume housecall based primary care for myself or my loved one

Yes

Please have HomeMD Housecall Services provide me with information about in-home primary care

Yes

Please set me up with a remote monitoring service so that my vital sign readings can be reviewed in real-time by my provider

Preferred Remote monitoring Service

BP Cuff

Glucometer

Weight Scale

Patient History

Medical History

Surgical History

Please list all medications ( include dosage strength and frequency )

Pharmacy Name

Pharmacy Phone Number

2ND Pharmacy Name

2ND Pharmacy Phone Number

Other Pertinent Information or Notes

[responsive device=phones]Please choose a service, and then scroll down to see the service description below.[/responsive] [responsive device=tablet]Please choose a service, and then scroll down to see the service description below.[/responsive]

Requested Services

Primary Care

Palliative Care

Wound Care

Podiatry Care

Behavioral Heath / Psych

Counseling Services (licensed medical social worker)

Remote Monitoring Services

Primary Care Services Description

Primary Care Services

Primary care in the home carried out by experienced nurse practitioners who have beenworking with homebound clients including geriatrics and their families for many years. Our providers are very much tuned in to the frustrations that geriatric clients and their families run into when trying to navigate a very complicated and fragmented medical care system. Diagnostics including labwork and imaging services are provided in the comfort of your livingroom, reducing the need for back and forth >trips to the PCP, which often require family members to take days off work. Our primary care program was designed to empower patients and their families with access to a level of comprehensive care that can’t be found anywhere else while accomplishing it all in one place, your living room.

Palliative Care Services Description

Palliative Care Services

Palliative Care ‐ Runs as a supplement to outside primary care for individuals who require frequent symptom management and/or for patients who need frequent, oftentimes unpredictable “check‐in’s” to put out fires secondary to chronic conditions; clients may keep their current primary care provider whom our clinical team will then coordinate care with.

Wound Care Services Description

Wound Care Services

Receive specialty wound care services in the comfort of your own home.

Podiatry Care Services Description

Podiatry Care Services

Podiatry Care – ankle, foot, and nail care in the home

Behavioral Heath Psych Care Services Description

Behavioral Heath / Psych Care Services

Nurse practitioners/medical providers who are able to make medication adjustments and order treatments centered around behavioral care services. Suitable for depression, isolation, anxiety, dementia, behaviors secondary to dementia, and abnormal psychology. Oftentimes complemented by our counseling services.

Counseling Services licensed medical social worker Description

Counseling Services (licensed medical social worker)

Services provided by licensed medical social workers in the home. Can also be provided telephonically through our tablet program.

Remote Monitoring Services Description

Remote Monitoring Services

Cloud connected blood pressure cuffs, weight scales, and diabetic glucometers that report readings to our office. These devices monitor and report to our provider staff when vital sign readings indicate that there may be a problem. Oftentimes when our providers are alerted to vital signs that may be of concern, this may indicate a need for intervention, which our providers can take either onsite or telephonically.

Ask us any questions or share details ...

Yes

I HAVE READ OR HAVE HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT; I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAVE HAD THESE QUESTIONS ADDRESSED TO MY SATISFACTION.*

Submitters Status *

I am the Patient

I am the Health Advocate

*Patients or Advocates Signature of Consent [responsive device=phones]Please flip your phone sideways when signing this form[/responsive] [responsive device=tablet]For tablets, please refresh your browser to erase the signature. NO info will be lost[/responsive]

Type in Your Name *

Date of Consent : [wpdts item="date"]

I have read and understand the privacy policy *

Yes.

I have read the and understand the Terms & Conditions*

I have read the Electronic Record and Disclosure *

Yes.

Patient Intake and Consent Form

Patient Intake and Consent Form

Patients Address

Billing Address (if different than patients primary address)

Patient Residence Info

Primary Insurance Information :

Secondary Insurance Information :

Emergency / Health Care Advocate

Primary Care Information

Patient History

Primary Care Services

Palliative Care Services

Wound Care Services

Podiatry Care Services

Behavioral Heath / Psych Care Services

Counseling Services (licensed medical social worker)

Remote Monitoring Services

Our Services

Quick Links

Useful Help