Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Enter the patient's name, date of birth, gender, address, city, state, and zip code. Include the patient's cell phone and home phone numbers, along with an authorized contact's name and phone number. If applicable, provide the patient’s email address and indicate if they are currently being seen by a Home Health Agency or are in hospice care.
3. In the patient insurance information section, provide details of the patient's primary and secondary insurance. Include the policy and group numbers for each insurance provider. If there is other insurance, make sure to fill in the respective information.
4. Complete the physician information section by entering the physician's name, NPI number, and address. Ensure to include the city, state, zip code, and main contact’s name, phone number, and fax number.
5. Fill out the referrer information. State who referred the patient, along with their phone number, organization, and email.
6. Proceed to the HCD representative information section, providing the representative’s name.
7. In the supplies needed section, mark all applicable boxes for urology supplies, wound care supplies, ostomy supplies, incontinence supplies, and diabetes supplies. Make sure to specify product numbers where required.
8. For diabetes supplies, indicate if a meter is needed, how often blood glucose testing will occur, and complete the details for any necessary supplies.
9. The patient must be informed that Home Care Delivered will contact them regarding medical supplies. Provide the date and ensure a signature from the physician, nurse, or authorized staff member. Note that stamped dates and signatures are not acceptable.
10. After filling out all necessary fields, ensure to review the form for accuracy, then save your changes. You can download, print, or share the completed form as needed.

Complete your Home Care Delivered Order Form online today for efficient processing of medical supplies.