Patient Intake and Consent Form Contact Us! Thank you {{patient_first_name}} for submitting your Patient Intake and Consent Form information to HomeMD Health.We will contact you within 1 business day. Notice of ACO Participation Medicare Shared Savings Program ACO 11https://www.homemdhealth.com/wp-content/plugins/nex-formstruehttps://bestbuy.commessagehttps://www.homemdhealth.com/wp-admin/admin-ajax.phphttps://www.homemdhealth.com/patient-intake-and-consent-formyes1fadeInfadeOut Patient Intake and Consent FormPlease 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 First Name*Patient Last NamePatient Date Of Birth *Email Primary Phone Primary Phone Type: Home Phone Cell Phone Secondary Phone Secondary Phone Type: Home Phone Cell Phone Best time to call 8AM - 11AM11AM - 1PM1PM - 3PM3PM - 5PMBest way to contact you By Phone By EmailSSN or Medicare Card #*Gender: Male Female Other Marital Status: Single Married Divorced Separated*Would You Like to be Notified of Consent Status: Yes No *Patient's Race/Ethnicity: Asian Black/African Caucasian Hispanic/Latino Other Patient's Race/EthnicityPlease specify the Patient's Race/Ethnicity:Patient's Primary LanguagePatients Address*Street Address Apt. or Suite*City *State*Zip Code Billing Address (if different than patients primary address) Street Address Apt. or SuiteCity StateZip Code *Patient lives in a . . . Residential House Assisted Living Facility Independent Living Facility Memory Care Unit Group HomeFacility Panel AreaName Of FacilityPrimary Insurance Information :Primary Plan Type Traditional Medicare Priority Health HAP (Health Alliance Plan) Humana Wellcare Molina Meridian PHP (Physicians health plan) Mclaren Health Plan Michigan Medicaid Other Other Primary Insurance Plan typePrimary Member ID # *Primary Group # Secondary Insurance Information :Secondary Plan Type Traditional Medicare Priority Health HAP (Health Alliance Plan) Humana Wellcare Molina Meridian PHP (Physicians health plan) Mclaren Health Plan Michigan Medicaid Other Other Secondary Insurance Plan typeSecondary Member ID #Secondary Group #Plan ( of Secondary Insurance )Submit Image of Insurance Card ( front )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Submit Image of Insurance Card ( back )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Submit Image of State ID / Driver License ( front )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Submit Image of State ID / Driver License ( back )Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Emergency ContactRelationship to the Patient * Self Guardian DPOA Health Care Advocate Relative OtherName of Emergency Contact Emergency Contact Cell Number Emergency Contact Home Number Emergency Contact Email Health Care Advocate / DPOA / GuardianMedical - DPOAFinancial - DPOAGuardiansHealth Care AdvocateOtherMedical - DPOAMedical - DPOAUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Financial - DPOAFinancial - DPOAUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf GuardiansGuardianUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Health Care AdvocateHealth Care AdvocateUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf OtherOtherUpload Supporting DocumentsMaximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Primary Care Information( So that we can coordinate care and/or retrieve records, if we are assuming primary care )Current or Former PCPs NameCurrent or Former PCPs Phone #Current or Former PCPs Fax #YesPlease have HomeMD Housecall Services assume housecall based primary care for myself or my loved oneYesPlease have HomeMD Housecall Services provide me with information about in-home primary careYesPlease set me up with a remote monitoring service so my vital sign readings can be reviewed in real-time by my providerPreferred Remote monitoring ServiceBP CuffGlucometerWeight ScaleTelehealth Questions1. Would you be agreeable to a vitual visit if necessary? Yes No2. Do you have a cell phone/tablet/computer ? Yes No3. Would you need assistance from one of our clinical liaisons to conduct this visit ? Yes No Please list all medications ( include dosage strength and frequency )Upload Digital Medication List *(Optional)Maximum 10 MB file size ( jpg, jpeg, png, pdf ) gif,jpg,jpeg,png,psd,tif,tiff,pdf Pharmacy NamePharmacy Phone Number2ND Pharmacy Name2ND Pharmacy Phone NumberOther Pertinent Information or Notes*Requested Services --Select-- --Select-- Primary Care Primary Care Palliative Care Palliative Care Podiatry Care (Facility Patients Only) Podiatry Care (Facility Patients Only) Behavioral Heath / Psych Behavioral Heath / Psych Counseling Services (licensed medical social worker) Counseling Services (licensed medical social worker) Remote Monitoring Service Remote Monitoring Service Please choose a service, and then scroll down to see the service description below.Primary Care Services DescriptionPrimary Care ServicesPrimary 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 DescriptionPalliative Care ServicesPalliative 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.Podiatry Care Services DescriptionPodiatry Care ServicesPodiatry Care – ankle, foot, and nail care.Behavioral Heath Psych Care Services DescriptionBehavioral Heath / Psych Care ServicesNurse 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 DescriptionCounseling 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 DescriptionRemote Monitoring ServicesCloud 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 ...YesI 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 Guardian DPOA Health Care Advocate Relative Other *Patients or Advocates Signature of Consent Please flip your phone sideways when signing this form, For tablets, please refresh your browser to erase the signature. NO info will be lost.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*Yes.SUBMIT