How did you hear about HCD?
IN CASE OF EMERGENCY CONTACT
Does patient have primary care physician or is patient PRN?
If PRN, Brielfy Explain the Situation in the box below:
Does Patient Live in a Group Home or Facility?
Is Patient currently serviced by Hospice or Home Health?
Does pt have any chronic illnesses or require any special skilled nursing needs? Briefly describe in box below:
* Required information
** Medicare part B only covers 80% of our services after the deductible is met. A supplemental (secondary) insurance may or may not cover the remaining 20%, so please provide additional information accordingly. House Call Doctors cannot accept patients with Medicaid as secondary and cannot bill dual-eligible patiens. If no supplemental (secondary) insurance is listed, a credit/debit card or check will be required; please include that information below.
Credit/Debit Card Information
Name as it appears on card:
Cardholder billing address & ZIP code:
Card number/ Expiration date/ Security code: