Get Intercare Vascular Diagnostic Center Patient Intake Form Testing Facility Name: Site Id#: Address

Completing the INTERCARE VASCULAR DIAGNOSTIC CENTER PATIENT INTAKE FORM is crucial for ensuring your medical needs are accurately addressed. This guide provides a comprehensive overview of each section of the form, enabling you to fill it out effectively and efficiently.

Follow the steps to successfully complete the patient intake form.

1. Click ‘Get Form’ button to access the intake form and open it in your document viewer.
2. Begin by entering the testing facility name and site ID number in the designated fields. This information is essential for identifying the specific location for your care.
3. Fill in the address of the facility. Ensure that the address is complete and accurate to avoid any communication issues.
4. Provide your telephone number and fax number if applicable. This contact information will help the center reach you if needed.
5. In the patient demographics section, enter your first name, last name, middle initial, and date of birth. Make sure to fill in your correct name as shown on your identification documents.
6. Indicate your sex using the M/F options provided, and select your race from the list if applicable.
7. Enter your Social Security Number in the appropriate field. This information is often used for insurance purposes.
8. Identify the responsible party for billing purposes, selecting from patient, insurance, or other options based on your circumstances.
9. Input the date of service, the name of your insurance provider, and your patient ID number. Make sure that all information is current.
10. Enter your age, height, weight, and Body Mass Index (BMI) in the designated fields to provide a complete health profile.
11. Review the risk factors checklist carefully and indicate 'Yes' or 'No' for each condition that applies to you. Please read the criteria associated with each risk factor to ensure accurate responses.
12. Complete the 'Test Performed' section by entering the relevant CPT codes and descriptions based on the tests you are undergoing.
13. Fill in the result fields for total and HDL cholesterol as per your recent lab results.
14. Complete the indication section by entering the relevant ICD codes and diagnoses that apply to your medical history.
15. In the referral section, provide your name and ID number, along with a brief patient history and reasons for referral.
16. Check the necessary procedures needed as indicated on the form.
17. Have the requesting physician sign and enter their license number to finalize the form.
18. After reviewing the entire form for accuracy, save your changes, and choose to download, print, or share the completed document as required.

Complete your documents online today to ensure a smooth and efficient intake process.