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Pharmacy On Boarding Paperwork
New Patient Intake Form

New Patient Intake Form, Customer Agreement

Please fill out and sign both forms. By filling these out and signing, KLTC will be authorized to bill your insurance. Please attach a photo/scanned image of the front and back of the insurance to the intake page. Give us a call with any questions or issues: Leslie Durbin 269.388.4850 ext: 350. Thank you.

*mandatory fields

Your First Name*

Your Last Name*

Your Email Address *

Patient Name

Patient DOB

Facility Name

Hospice Company

Medicare Number

SSN

Drivers License #

Allergies

Michigan Medicaid

Payee Name

Address

Phone #1

Phone #2

Current Pharmacy

Location

Phone #

Primary Care Physician

Psychiatric Care Physician

Printed Name

Relationship

Name of Facility

Address 2

Patient Full Name

Maiden or other name

DOB

Start Date for Auth to Disclose

End date for Auth to Disclose

End Date for Auth to Disclose OR unlimited

Phone Number

Verbal Pass Code

Items that can and cannot be discussed

Name(s) HIPAA may be discussed with

Email Address

Telephone Number

Relationship to Patient

Explain patient and representative's relationship