Patient intake form (printable)

Print it, fill it in, and have it ready when you call — or hand it to our delivery staff. It is every question we will ask, on one page.

Questions? Call (800) 304-7030 All guides & forms

For your privacy, please do not email a completed form — email is not a secure channel for health information. Hand it to our delivery staff, mail it to PO Box 1484, Boca Raton, FL 33429-1484, fax it to (800) 594-1226, or simply call (800) 304-7030 and read it over: we will take the details securely either way.

Patient intake formScotts Medical Supply

Patient

Name: _______________________________________________________

Date of birth: ____________________ Phone: ____________________

Address: ____________________________________________________

City: ______________________ State: ______ ZIP: __________

Coverage

Primary insurance: ______________________ Member ID: ______________

Secondary insurance: ____________________ Member ID: ______________

What you need

Equipment / supplies: _______________________________________________

Reason (what happened, or the diagnosis if you know it): ________________________

If a supply you already use — the manufacturer reference number from the box: ____________

Prescriber

Doctor / clinic: ______________________________ Phone: ____________

Caregiver (if any)

Name: ______________________________ Phone: ____________

Delivery access

Stairs? ▢ No ▢ Yes Elevator? ▢ No ▢ Yes Gated community or door code? ▢ No ▢ Yes: __________

Best days / times someone is home: _____________________________________

Signature

Signature: ________________________________ Date: ____________

This form starts a conversation; it is not an order, a contract, or a coverage determination. Your benefits are verified and your share explained before anything is delivered.

Scotts Medical Supply · (800) 304-7030 · fax (800) 594-1226 · scottsmedsupply.com · 1746 Costa Del Sol, Boca Raton, FL 33432-1747

Getting started Paperwork checklist Plans we accept

Not sure where to start?

Call us and tell us what happened — a surgery, a new diagnosis, a discharge date, a supply you keep running out of. We will tell you what is usually needed, check your benefits, and ask your prescriber for the order if you do not have one yet.

Call (800) 304-7030 Send a message See accepted plans