Home Health Services Order Form
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WELCOME
to the
Georgetown Pharmacy
Georgetown Health Care Center
5605 Merriam Drive
Merriam, KS. USA 66203
(800)279-3026

HOME HEALTH SERVICES ORDER FORM

***** COMPLETE THIS SECTION IF THE PERSON ORDERING IS NOT PATIENT *****

Person Ordering Phone
Facility or Organization
Address
E-Mail Address
***** PATIENT INFORMATION *****

Name Date of Birth
Address1
Address2
City State Country
Zip
Phone E-Mail Address
Physician
Diagnosis
***** BILLING INFORMATION *****

Bill to: Pat. Hosp. Medicare Medicaid Ins. Hospice HHA Other
Billing information (id, policy number, group number, telephone number, etc):
Use: Visa Mastercard Discover No. Exp.
***** PRODUCTS AND/OR SERVICES TO BE ORDERED *****


***** DISPERSMENT INFORMATION *****

Deliver Pick Up UPS Mail
When:
Where:
Please enter any additional comments or requests:



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