New Patient Information Form - Medical Supply | WONACE Medical Supply and Equipment Store | Houston, TX.

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We accept Insurances, Medicare, and Medicaid

New Patient's Form

SAVE 20% OFF your first AUTOSHIP

Choose from other specific Medical Supplies Forms:

Wheelchairs & Scooters

Freestyle Libre and Dexcom

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

Last name

Phone

Email

Street Address

Apt Number

City

Region/State/Province

Postal / Zip code

Country

Date of Birth

Select an option *

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

Upload File

Upload supported file (Max 15MB)

Upload Doctor's prescription

Upload File

Upload supported file (Max 15MB)

Delivery Options *

Pick Up at Facility

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

Do you need Home HealthCare Services? *

Yes

No

Delivery/Shipping Address

How did you hear about Us?

Enter Other

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.

Thanks for your submission, We'll get back to you right away!

Street Address

Apt Number

City

Region/State/Province

Postal / Zip code

Country

Street Address

Apt Number

City

Region/State/Province

Postal / Zip code

Country

Street Address

Apt Number

City

Region/State/Province

Postal / Zip code

Country

Street Address

Apt Number

City

Region/State/Province

Postal / Zip code

Country

First Aid & Woundcare

Ostomy & Urology

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Therapy & Rehabilitation

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