Intake Form

Patient Intake Form (#3)

Step 1: Patient Information

Patient First Name

Patient Last Name

Patient Phone no.

Patient Address

Perferred Language

Patient Gender

Type of Visit

Home Visit (Physical)

TeleHealth

Date of Birth

Step 2: Insurance Information

Medicare Part B, Insurance #

Reason for Visit Request

Please select your preferred MD (Medical Director) to sign the referral*

You're now able to select MD in order streamline your paperwork

MOHAMMAD SIDDIQUI | NPI: 1356963185

RAFAEL PENUNURI | NPI: 1831270362

MICHAEL K. WENSLEY, MD | NPI: 1841336740

Additional Comments

Step 3: Preferred Facility

If we have worked together in the past you may just fill the facility name, phone, & contact name.

Name of Facility

Address

Contact Person

Email Address

Phone Number

Read Terms of Service

Purpose of Request (CMS-Specific) This request is made solely to obtain an independent face-to-face medical evaluation in accordance with 42 CFR §424.22(a) to determine whether the Medicare beneficiary meets Medicare coverage criteria for home health services, including medical necessity, homebound status (42 CFR §409.42), and need for intermittent skilled services (42 CFR §409.44). No certification or Plan of Care is implied by this request. Clinical Independence Statement The evaluating provider shall perform a personally conducted face-to-face encounter, exercise independent medical judgment, and certify services only if Medicare criteria are met. The provider is not required to certify home health services. Fraud & Abuse Compliance Attestation No payment, remuneration, incentive, or referral obligation exists or is offered in connection with this request, in compliance with the Anti-Kickback Statute, Stark Law, False Claims Act, and applicable California law. Patient Freedom of Choice Acknowledgment The Medicare beneficiary has been informed of their right to choose any qualified provider or home health agency. Billing & Documentation Responsibility The evaluating provider may bill Medicare directly for covered services. The home health agency will not prepare or modify clinical documentation. I acknowledge that checking the box below constitutes my legal electronic signature and agreement to these terms.

I Agree that I have read and consent to the terms of service above

Prime Care Medical Group, Inc. delivers compassionate, high-quality healthcare directly in the comfort and convenience of your home. Our comprehensive, modern healthcare services are designed to enhance the quality of life for homebound patients while also providing valuable support to their caregivers.

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Privacy Policy

This Privacy Policy (“Privacy Policy”) describes how Remedial Patient Care (“Remedial,” “we,” “us,” or “our”) collects, uses, and discloses personal information through the websites we operate that link to this Privacy Policy, including https://remedialpc.com/ . This Privacy Policy does not apply to personal information collected through other online services or website subdomains that are maintained by Remedial but do not include a link to this Privacy Policy. Please note, this Privacy Policy does not govern our collection, use, or disclosure of protected health information (PHI) or our privacy practices related to any patient portals or mobile applications you may access while logged in. Those activities are subject to the federal Health Insurance Portability and Accountability Act (HIPAA) and are separately addressed in Remedial’s Notice of Privacy Practices. We reserve the right to revise this Privacy Policy at any time, as indicated by the “Last Updated” date shown below. If we make any material changes, we may provide additional notice as required by law.

Collection of Personal Information

We, along with our trusted vendors, may collect personal information through our Sites. This may occur, for example, when you submit details via web forms, such as your name, phone number, email address, type of insurance, employer information, and a description of your inquiry. If you apply for a job or fellowship, we may also collect professional, educational, or employment-related information, which may include your résumé, certifications, eligibility documentation, and demographic details. In addition, our Sites may feature interactive tools, such as a customer service chat function. When you use these features—whether interacting with a virtual or live agent—the contents of the chat may be recorded and stored as a transcript. By submitting personal information through these interactive features, you acknowledge and agree that our vendors may process this information on our behalf in order to provide the services you request.

Tracking Technologies

We, along with our vendors, may use tracking technologies—such as cookies, web beacons, and pixels—on certain pages of our Sites to collect information. This information may include IP addresses, device identifiers, pages visited, approximate geographic location, content you interact with, time and date of visits, clicks, movements, scrolling behavior, keystroke activity, and browser details. These tracking technologies are used to enhance site functionality, perform analytics, improve overall performance, and deliver targeted marketing. Some of these technologies may collect information about your online activities over time and across different devices or websites. We may also combine this information with other data we maintain about you to better understand your preferences and provide a more personalized experience.

Use and Disclosure of Personal Information

We, along with our vendors, may use or disclose personal information collected through the Sites for the following purposes:

Communicating with you — responding to inquiries, sending newsletters, and providing information about our services.
Processing job applications — including reviewing submissions and conducting eligibility assessments.
Maintaining and securing the Sites — ensuring optimal performance, safety, and integrity.
Meeting legal obligations — such as complying with court orders and cooperating with law enforcement authorities.
Facilitating business transactions — including mergers, acquisitions, or transfers of assets.
Converting data — converting personal information into de-identified, anonymized, or aggregated data as permitted by law.

Where required by law, we will obtain your consent before using or disclosing your personal information for purposes that are not compatible with the original purpose for which it was collected.

Your Choices

If you have a registered account on the Sites, you can update your personal information and manage your preferences through your account settings. You may also opt out of receiving promotional emails from us by clicking the “unsubscribe” link included in any such email.

If you need additional assistance updating or deleting your account and cannot do so through your settings, please contact us using the contact information provided on the Sites.

Links to Other Websites

The Sites may include hyperlinks to external websites not owned or controlled by Remedial Patient Care. We are not responsible for the content or privacy practices of these external sites.

Data Security

We take reasonable measures to help protect personal information collected through the Sites from loss, theft, misuse, unauthorized access, disclosure, alteration, or destruction. However, no data transmission over the Internet is entirely secure.

Consent to Receive Communications

By providing your mobile number, you agree to receive informational and service-related communications via calls or text messages. Message and data rates may apply. To stop receiving text messages, reply STOP.

California “Shine the Light”

California residents may request a list of external parties to whom we have disclosed certain types of personal information during the preceding calendar year for marketing purposes. To submit a request, contact us at intake@remedialpc.com or at our mailing address.

Contact Us

If you have any questions about this Privacy Policy, you may contact us at:

Remedial Patient Care

1451 RIMPAU AVE. SUITE-213, CORONA, CA 92879
Tel: 951-268-6272
Email: intake@remedialpc.com

This Privacy Policy is effective as of the Last Updated date above.

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