Follow the steps to accurately complete your house call request form.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the patient's full name in the designated field. This information is vital to identify the individual requesting the house call.
3. Fill in the address details, including street address, city, state, and zip code. Ensure that all information is correct to prevent any delivery issues.
4. Provide the primary phone number and an alternate phone number in their respective fields for communication purposes.
5. Enter the patient's date of birth. This helps verify the identity of the patient.
6. Indicate the patient's sex by circling either 'Male' or 'Female'.
7. In the insurance information section, write the insurance name, ID number, and group number, if applicable.
8. Proceed to fill in the physician's information, including the physician's name, NPI or UPIN number, address, city, state, zip code, phone number, and fax number.
9. Provide the ICD-10 code(s) relevant to the tests required. This is essential for billing and medical record purposes.
10. List the test names required by entering them in the corresponding field.
11. If there are any special instructions for the tests, please enter them in the designated area.
12. Indicate if the patient requires fasting by circling 'YES' or 'NO'.
13. Fill in the frequency, start date, and end date for the tests in the respective fields.
14. Circle 'YES' or 'NO' to confirm if the patient is medically homebound.
15. Lastly, the physician must sign the form to authorize the request before submission.
16. Once all sections are complete, users can save changes, download, print, or share the filled-out form as needed.

Take a moment to fill out the PA Tender Care Phlebotomy House Call Request Form online now.