Please provide the following contact information. At the end of this form please print it, sign it and mail it to The address at the top of the page.
| First Name | Date of Birth | ||
| Last Name | Sex |
Male Female |
|
| Middle Initial | Height | ||
| Permanent Address | Weight | ||
| Permanent Address (cont') | |||
| Permanent City | Married | ||
| Permanent State | |||
| Permanent Zip/Postal Code |
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| Permanent Phone | |||
| Local Address | |||
| Local Address (cont') | |||
| Local City | |||
| Local State | |||
| Local Zip/Postal Code | |||
| Local Phone | Medicare Coverage | ||
| FAX | Medicare Number | ||
| Accident Date | |||
| Employment by: | Student | Other | |
| Insurance Information | Insured's Name | ||
| Insurance Company | Policy Number | ||
| Contact Name | Employee Group # | ||
| Address | Po Box | ||
| City | State | ||
| Zip | Phone | ||
| Doctor Information | |||
| Last Name | First Name | ||
| Address | Suite | ||
| City | State | ||
| Zip | Phone | ||
| Diagnosis | Fax | ||
| Care Giver Guardian Next of Kin |
Phone # | ||
| Referral | Phone # | ||
| I authorize any holder of
medical information about me to release to Elite Home Health Care,
Inc. and the Health Care Financing Administration and its agents any
information needed to determine these benefits. I authorize the
release of the information in my file to any governmental agency
such as Medicare, Medicaid, and Joint Commission on Accreditation of
Healthcare Organizations, etc. I the undersigned, by signing hereto,
release Elite Home Medical Supplies from any and all injuries
arising from the equipment received from Elite Home Medical
Supplies.
If covered by Medicare I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. |
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| Signature (required after printing) |
|
Date | |