| Hock's Pharmacy | |
| 535 SOUTH DIXIE DRIVE | |
| VANDALIA, OHIO 45377 | |
| 800 866 4997 voice 937-898-9340 Fax | |
| E-Mail---patientservices@hocks.com | |
| Website---www.hocks.com | |
| ENROLLMENT FORM WORKSHEET----Print This form | |
| This form is required to bill Medicare on your behalf. | |
| Please complete this form entirely Then mail the completed form to the address above or Call one of our Customer Service Representatives at the Toll Free Number above. | |
| PERSONAL INFORMATION | |
| Patient Name______________________________________________ | |
| Primary Street Address_____________________________________________ | |
| Primary City__________________________________ | |
| Primary State_________________________________ | |
| Primary Zip Code________________ | |
| Primary Telephone Number_(_______)______________________ | |
| Sex__________ | |
| Marital Status________________ | |
| Date of Birth_____/_____/___________ | |
| Social Security Number_________________________ | |
| Medicare Number______________________________ | |
| Secondary Street Address_____________________________________________ | |
| Secondary City__________________________________ | |
| Secondary State_________________________________ | |
| Secondary Zip Code________________ | |
| Secondary Telephone Number_(_______)______________________ | |
| E-mail Address_____________________________________________ | |
| MEDICAL INFORMATION | |
| Doctor's Name________________________________________________ | |
| Doctor's Street Address__________________________________________ | |
| Doctor's City__________________________ State____________________ Zip_____________ | |
| Doctor's Telephone_(_____)______________Approximate Date of Last Visit__________________ | |
| Spouses' Name_______________________________________ | |
| Alternative Contact Person____________________________________________ | |
| Telephone_(_____)___________________________ | |
| Facility_______________________________________________________ | |
| SUPPLEMENTAL INSURANCE INFORMATION | |
| Do you have a supplement to Medicare? Yes____ No____ | |
| Insurance Company Name_________________________________________ | |
| Street________________________________________________ | |
| City_________________________________________ | |
| State_____________________________ | |
| Zip__________________ | |
| Telephone Number_(_____)_______________________ | |
| Policy Number__________________________________ | |
| Group Number___________________________________ | |
| IF YOU ARE NOT THE PRIMARY INSURED PERSON, PLEASE COMPLETE! | |
| Name of Policy Holder_____________________________________________ | |
| Date of Birth of Policy Holder______/_______/___________ | |
| Social Security Number of Policy Holder_________________________________ | |
| Sex_________ | |
| Relationship to Patient____________________________________ | |
| ARE YOU CURRENTLY USING INSULIN? Yes____ No____ | |
| How many times do you test your blood glucose level per day?___________ | |
| What brand of blood glucose meter do you currently own?_______________________ | |
| Did Medicare cover your present meter? Yes____ No____ | |
| Are you interested in a new Meter? Yes____ No____ | |
| ANY QUESTIONS CALL TOLL FREE 1-800-866-4997 |