Scott Cashell -MHB Training Team -48174 Sign Out
NEW PATIENT INFO.
(mm/dd/yyyy)
Male Female
Race
1 - American Indian/Alaska Native 5 - Native Hawaiian/Pacific Islander
2 - Asian 6 - White
3 - Black or African-American UK - Unknown
4 - Hispanic or Latino
Primary Referring Physician
Case Manager
Referral Source
Default Payer
M0063 Medicare No.
NA
M0065 Medicaid No.
NA
Health Insurance Claim No. (if no MX or MC)
SSn
NA
Current Payment Sources(M0150)
0 - None; no charge for current services 1 - Medicare (traditional fee-for-service)
2 - Medicare (HMO/managed care) 3 - Medicaid (traditional fee-for-service)
4 - Medicaid (HMO/managed care) 5 - Workers' compensation
6 - Title programs (e.g., Title III, V, or XX) 7 - Other goverment (e.g., CHAMPUS, VA, etc.)
8 - Private insurance 9 - Private HMO/managed care
10 - Self-pay 11 - Other
UK - Unknown
Home Directions
Specific Concerns
M1100Living Sitution
Emergency Priority
Bill Patient For Services
YES NO
Automatically Verify Eligiblity?
YES NO
Keep in Lookups
YES NO

Home Care Business Services. 190 US Route 1, Falmouth,ME 04105.
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info@myhomecarebiz.com.
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