Home Health Services Order Form

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

HOME HEALTH SERVICES ORDER FORM

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:

FAX COPY OF THIS SHEET TO 913-722-1600 or EMAIL ghccrx@gmail.com or CALL 913-363-0313
To place an order or for additional information: ghccrx@gmail.com