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DME Intake Form

Patient Information

MM slash DD slash YYYY
Name(Required)
Address
Date of Birth

Responsible Party Information

Same As Patient?
Name
Address
Date
Accepted file types: jpg, png, pdf, Max. file size: 300 MB.

Insurance Information

If no, please make payment arrangements with our business office.
Policy Holder Date of Birth
Accepted file types: jpg, png, pdf, Max. file size: 300 MB.
Policy Holder Date of Birth
Consent For Payment
I hereby authorize payment of medical benefits billed to my insurance by Fulton Pharmacy, LLC dba Whitesell Home Medical Supply. I have listed all health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made by my insurance if Fulton Pharmacy do not participate with my insurance. I hereby authorize Fulton Pharmacy, LLC dba Whitesell Home Medical Supply to use and/or disclose my health information which specifically identities me or which can reasonably be used to identify me to carry out my treatment, payment, and healthcare operations.

I understand that while this consent is voluntary, if I refuse to sign the consent, Fulton Pharmacy, LLC dba Whitesell Home Medical Supply can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions that Fulton Pharmacy, LLC dba Whitesell Home Medical Supply took before receiving my revocation.
Date
Printed Name

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Whitesell Pharmacy
236 North Market St.
Frederick, MD 21701
Phone: 301.662.4848
Fax: 301.620.0668

Hours
Monday – Friday: 8:30AM – 5:00PM
Saturday: 8:30AM – 2:00PM

Whitesell Home Medical Supply
622 N. Market Street
Frederick, MD 21701
Phone: 301.663.6464
Fax: 301.663.3207

Hours
Monday – Friday: 8:30AM – 5:00PM
Closed Saturday

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