PEAKS & PLAINS MEDICAL, INC.
RESIDENT SIGN UP FORM
INSURANCE

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Patient Information
Name*: Name is required Phone*: Phone is required       Phone must match: xxx-xxx-xxxx
Gender*:

Male Female
Gender is required
Birth Date*: Birth Date is required
Height*: Height is required Weight*: Weight is required
Do you have a latex allergy?*:

Yes No
Answer is required
How did you hear about us?*: Hear About is required
Facility Information (if residing in)
Facility:
Facility Type:
Address:
City:
State:
Zip:
Contact Name:
Phone:
Fax:
Physician Information
Primary Physician*:
Primary Physician is required
Phone*:
Phone is required       Phone must match: xxx-xxx-xxxx
Fax:
Address*:
Address is required
City*: City is required
State*:
State is required
Zip*: Zip is required

To comply with insurers regulations, all information indicated is required. A copy of the client's Insurance card(s) must accompany this order. The above named patient requires these items for medical purposes.

    I, the undersigned, hereby attest that the above person is covered by insurance and if there is any change in coverage, I will notify Peaks & Plains, Inc. immediately. I will be responsible for charges incurred from not providing such notification.
    I authorize Peaks & Plains, Inc. to obtain and release my medical and/or other information necessary in order to process my claims(s) and verify eligibility for coverage of item(s) supplied. Also, I acknowledge that I have received a copy of the Notice of Privacy Practices, which provides a description of uses and disclosures of protected health information; the Supplier Standards, which inform you of the regulations regarding covered supplies; the Client Bill of Rights and the Protocol for Resolving Complaints.

Signature of Patient or Person Authorized to Sign for Patient*
(Must have POA or Authorization in Writing to Sign on Behalf of the Patient)
Date of Signature*: Signature Date is required Sales Person*: Sales Person is required
Reason patient is unable to sign (if applicable):
Insurance Information* (at least one)   One type of Insurance is required  
Medicaid #: Medicare #:
Other Insurance:
POA Information
POA: Phone:
Address: City:
State: Zip:
Product Request
Product Type Size Brand/Product #

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Our Locations

Spokane Valley, WA

Main Office/Warehouse

6326 E Trent Ave Ste A
Spokane Valley, WA 99212
1-800-585-4201

 

Retail Store

13524 E Sprague Ave
Spokane Valley, WA 99216
509-927-0991