Patient Intake – MediHarbor

Patient Info

Name, address, DOB, and contact details

Insurance Info

Insurance provider, member ID, group number

Equipment Needed

What equipment, diagnosis, and doctor info

📋 Have These Handy Before You Start

✅ Insurance card (front and back)

✅ Your doctor's name and phone number

✅ Prescription or written order (if you have one)

✅ Diagnosis or condition description

Don't have everything? That's OK — complete what you can and we'll follow up to gather the rest.

Patient Intake Form

Step 1 — Patient Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Street Address *

City *

ZIP Code *

Step 2 — Insurance Information

Insurance Provider *

Member ID

Group Number

Policy Holder Name

Step 3 — Equipment Needed

Equipment Needed *

Diagnosis / Condition

Prescribing Doctor's Name

Doctor's Phone Number

Upload Prescription (PDF, JPG, PNG — optional)

Max 10MB. Your file is stored securely and handled in accordance with HIPAA regulations.

I consent to MediHarbor collecting and using the information provided to verify my insurance, process my DME order, and contact me about my request. This information is handled in accordance with HIPAA regulations and will not be sold or shared with third parties.

🔒 HIPAA Compliant. Your information is encrypted, securely stored, and only used for processing your DME request. We never sell or share your personal health information.

Start Your Patient Intake

📋 Have These Handy Before You Start

Patient Intake Form

Step 1 — Patient Information

Step 2 — Insurance Information

Step 3 — Equipment Needed