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AccessPro HealthCare

Patient Intake Form

🔒 HIPAA Secure

Welcome to AccessPro HealthCare

Please complete this intake form so we can begin your home health care services. This takes about 5 minutes.

🔒 256-bit Encrypted ✓ HIPAA Compliant 📋 Medicare & Medicaid Accepted

Agency

Personal

Insurance

Medical

Emergency

Consent

🏠 Select Your Home Health Agency

Choose the agency that referred you to this form.

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Comfort Care Home HealthCare

NPI: 1801128962 · Chicago, IL · Medicare & Medicaid Certified

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iHeal: Health and Wellness Center

NPI: 1235785809 · Chicago, IL · Medicare & Medicaid Certified

👤 Personal Information

Please provide your basic personal information.

First Name *

Last Name *

Date of Birth *

Gender *

Home Address *

City *

State *

ZIP Code *

Phone Number *

Email Address

Preferred Language

💳 Insurance Information

Please provide your insurance details for billing purposes.

Primary Insurance *

Medicare ID / Member ID

Medicaid ID

Secondary Insurance

Referring Physician

Physician Phone

💋 Medical History

Please share your current medical conditions and medications.

Primary Diagnosis *

Additional Diagnoses

Current Medications

Allergies

Services Needed

Mobility / Ambulation Status

Additional Medical Notes

📞 Emergency Contact

Who should we contact in case of emergency?

Contact Name *

Relationship *

Phone Number *

Alternate Phone

Lives with Patient?

Authorized to Make Medical Decisions?

📋 Consent & Authorization

Please review and sign below to authorize home health services.

Authorization for Home Health Services

I authorize to provide home health services as ordered by my physician. I authorize the release of my medical information to Medicare, Medicaid, and other insurance carriers for billing purposes. I understand that I have the right to refuse treatment and to receive information about my plan of care. I acknowledge receipt of the Notice of Privacy Practices (HIPAA). I certify that the information provided in this form is true and accurate to the best of my knowledge.

I have read and agree to the HIPAA Notice of Privacy Practices *

I authorize home health services as described above *

I authorize billing to my insurance provider(s) *

Full Name (Print) *

Type your name above to generate signature options