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In Home Wound Care

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In Home Wound Care

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Home / Wound Care Intake

Wound Care Intake

PLEASE READ THIS SECTION CAREFULLY BEFORE FILLING OUT THE INTAKE FORMS:

– Once you complete the forms on this page, a Medicare Specialist will seek approval from Medicare for your In-Home Wound Care with Advanced Tissue Grafts that promote tissue regeneration

– This process usually takes between 72 hours and two weeks.

– Once you are approved, you may be contacted by the Medicare Specialist or Care Facility that will come to your home to provide treatment.

– Your information is kept secure and in compliance with HIPPA Mandates. There is NO COST to you for this treatment.

IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT US 888-709-8799

Medicare Consent – Please Complete this form first:

AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION RELEASE FORM

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email

Date Of Birth *

Medicare Identification Number: *

By signing this form, I authorize 1-800-MEDICARE to share my personal health information listed above to the person(s) or organization(s) I named on the form. I understand that my personal health information may be shared by the person(s) or organization(s) and may no longer be protected by law. *

Yes, I understand and agree.

to person(s) Name

Signature *

Clear Signature

Wound Care History / Authorization – Please Complete this form second:

Full Name: *

First

Last

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Best Phone Number: *

Date Of Birth: *

Email: *

MEDICAL HISTORY

Are you corrently receiving wound care treatment? *

Yes
No

Is the wound infected? *

Yes
No

Please describe your wound care history (Wound Vac, Collagen, Surgery etc): *

Please specify the exact location of your wound: *

Please let us know your Current Doctor's Name and Clinic Location *

Are you currently living in or have been admitted to a facility? *

Yes
No

Are you currently taking blood thinners? *

Yes
No

Have you ever diagnosed or treated for (check as many as apply) *

Diabetes
COPD
Heart Failure
Neuropathy
Kidney Failure or Disease
Liver Disease
HIV/AIDS
None of the above

Emergency Contact Name *

First

Last

Relationship to Patient:

Emergency Contact Phone Number: *

INSURANCE INFORMATION

insurance plan Signature

What type of Medicare do you have? *

Part A and B
Medicare Advantage Plan

If you have a Medicare Supplement (not Medicare Advantage) Please let us know what plan and company:

Medicare ID # (Red White and Blue card ONLY) *

Do you use any other insurance card at your Doctor's office? *

Yes
No

If yes, please explain:

If you have a Medicare ADVANTAGE Plan (Part C) please let us know the carrier: (Aetna, Humana, UHC, etc)

Does a Nurse or Caregiver come to your home? *

Yes
No

Please list any medications you are taking:

DOCUMENTS NEEDED

Please Upload a Picture of your Medicare Card/s

Click or drag files to this area to upload. You can upload up to 4 files.

Please Upload Recent Pictures of Your Wound:

Click or drag files to this area to upload. You can upload up to 4 files.

Additional Notes: Please let us know anything we should know about that may not have been mentioned:

By signing this form, I understand and acknowledge that this information is going to be shared with "Wound Care LLC" (Grafts Distributor) and "Senior Home Services Inc" (Remote Care Medicare Benefits Specialist) . Under the HIPAA Privacy Standards, I understand that parties who are not a party to this agreement may possibly redisclose the information for the purposes of coordinating care. *

Yes, I understand and agree.

Signature *

Clear Signature

Quick N Mobile Inc Hours of Operation:

Monday-Thursday 10am - 6pm EST

Friday 10am - 2pm EST

888-701-8799

321-701-3080

We are a Florida-based company. Please contact us for our mailing address.

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