Patient Intake Form

• Complete the Patient Intake Form and print out the form on your printer, or call us at 1-800-231-4276 and have one sent by facsimile.



• Fill out the form completely and have BOTH the referring doctor the patient sign it.



• FAX the completed form to 1-970-674-3061 and we will start the process of expediting the equipment to the patient.

Give us a call and we would be happy to stock your office with pre-printed Patient Intake forms.

Medcomdirect.com is a LOW COST-PREPAID ALTERNATIVE to provide patients with DME equipment that often requires lengthy prior authorization procedures, sometimes causing a delay in your care. Your insurance carrier may still cover this equipment. As a courtesy Medcomdirect.com will provide you with the required paperwork to submit your bill directly to your insurance.

Please note: Sales Tax will apply to patients in California, New Mexico and other states that have chosen to tax prescription items.

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