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MEDICAL SUPPLY

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- Insurance Breast Pumps
- Breast Pump Eligibility Form
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Wheelchairs & Scooters Form

New Patient Information Form

Please fill out this form as best you can so we can provide you with the most relevant service.

First name

Phone

Last name

Email

Address

Date of Birth

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Purchase

Rental

Payment Method

Cash

Insurance

Insurance Type

PPO

HMO

Enter Insurance name or Type (PPO or HMO)

Enter Item(s) Description (Model and Manufacturer)/(Lot, Serial Number and Expirations)

Upload Insurance card, ID card/License

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Upload Doctor's prescription

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Delivery Options

Pick Up at Facility

Deliver to Patient/Caregiver (5 miles from our location)

Do you need Home HealthCare Services?

Yes

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Delivery/Shipping Address

How did you hear about Us?

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Any additional comments?

I assign the right and responsibility to the Facility to bill (Insurance) on my behalf and accept payment for WONACE products and services provided to me, the Beneficiary. I understand that I am responsible to pay any deductible amount applied to the claims and the coinsurance, which is 20 percent of the allowable or approved charge for a product or service. I permit the Facility to release and collect my health information, and other information, as required (and as permitted by the HIPAA Regulations) from my health care providers and Medicare receiving payment from Medicare. I understand that this form will be maintained and made available to Medicare or its representatives.

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