care-management1

Patient Intake Form for PriceMDs Program

Referring Vendor

Employer Group

TPA/Stop Loss/PBM

BIN

PCN

Person Code

Relationship Code

Member First Name

Member Last Name

Member ID

Date of Birth

Phone Number

Email Address

*Must provide a phone number or email, preferably both

Member relationship to insured?

Member's preferred method of communication?

Preferred Days and Times

Is there a preferred time to be reached? (Hour)

Preferred Time (Minute)

Preferred Time (AM PM)

Time Zone

Medication Name

Enter member medication name

Medication Strength

(E.g. 40mg, 3ml etc.)

Frequency of Use

(E.g. Twice a day, once a week etc.)

Is this a new medication?

NoYes

*PriceMDs cannot provide the first dose of any new medication.

Member has been told that a PriceMDs Nurse Navigator will contact them about PriceMDs’ International sourcing program?

NoYes

Does member have a Real ID or Passport?

Submitted By

Phone Number

Note

Upload a copy of Real ID, passport, medical records, or any relevant documents.You can upload a maximum of 5 files, each up to 90MB.