3400 Olentangy River Road, Suite 200
Columbus, Ohio 43202
614 262-HAND (4263)
614-262-0822 (Fax)
Patient Intake Form
Financial Consent HIPPA
Therapy Insurance Information
HIPPA
Medicare Cap
Medicare Secondary Insurance
United Health Care Patient Form
UHC Patient Summary Form
Patient Information Letter
INSTRUCTIONS IF USING OUTLOOK
1. Open the form
2. Fill out the form
3. Click submit form (Outlook will open with the form attached)
4. Click send
5. Print if necessary
1. Open the form
2. Fill out the form
3. Click submit form (Outlook will open with the form attached)
4. Click send
5. Print if necessary
INSTRUCTIONS IF USING POP3 EMAIL (Yahoo, Gmail, Hotmail, Etc.)
1. Right click the form and choose Save Target As
2. Save the file to the desktop
3. Fill out the form
4. Click save (you do not need to click the ‘Submit Form’ button)
5. Open up your email software of choice
6. Compose a new email to patientinfo@handandmicro.com
7. Attach the form
8. Click submit in your email client
9. Print the form if necessary
1. Right click the form and choose Save Target As
2. Save the file to the desktop
3. Fill out the form
4. Click save (you do not need to click the ‘Submit Form’ button)
5. Open up your email software of choice
6. Compose a new email to patientinfo@handandmicro.com
7. Attach the form
8. Click submit in your email client
9. Print the form if necessary
ErgoScience – F.C.E.
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Wound Care Supplies Sold
Continuing Education Event
4/17/2010
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