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Online Bill Pay
Intake Assessment
Equipment Requested
*
Employee (If Known)
Height
*
Weight
*
Sex
Male
Female
First name
*
Middle Initial
Last name
*
Phone
*
Phone Type
*
Mobile
Home
Work
Alternate Phone
Phone Type
Mobile
Home
Work
Email
*
Permanent Address 1
*
Permanent Address 2
Permanent City
*
Per. State
*
Permanent Zip
*
Local Address 1
Local Address 2
Local City
Local State
Local Zip
Alternate Contact (Required for Insurance Orders)
Alternate Contact Relation
Alternate Contact Phone
Phone Type
Mobile
Home
Work
Doctor Name(Required for Insurance Orders)
Doctor Phone (If Known)
Primary Insurance Name (Required for Insurance Orders)
Primary Insurance Policy # (Required for Insurance Orders)
Secondary Insurance Name
Secondary Insurance Policy #
Date of Birth (Required for Insurance Orders)
Month
Month
Day
Year
Diagnosis (Required for Insurance Orders)
Is the equipment needed as the result of a fall?
Yes
No
Are there any visual, auditory, or verbal limitations?
No
Yes
Power of Attorney Name, if applicable. (Documentation Required)
I give permission for Health Aid Company, Inc and its staff to leave messages concerning the requested medical equipment on the following:
Phone
Alternate Phone
Alternate Contact Phone
Identification & Insurance Cards
Upload File(s)
Prescriptions & Medical Documentation
Upload File(s)
By typing my name, I declare that the information provided on this form is complete and correct and that I will notify Health Aid Company, Inc if any changes occur. I also authorize Health Aid Company, Inc permission to verify the information provided.
*
Submit
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