New Patient Intake Form

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New Patient Intake

Welcome to 1st Care Management

Thank you for choosing 1st Care Management for your in-home healthcare needs. This intake form
allows us to learn about your medical history, current conditions, and insurance information so we can
build a personalized care plan before your first visit.

What You Will Need to Complete This Form

Before you begin, it is helpful to have the following information available. You can also save your progress and return later if needed

Your current medication list (drug names, dosages, and frequency)
Your insurance card (provider name and ID number)
Names of physicians or medical facilities you have visited in the last 6 months
Any recent discharge notes, lab results, or medical records (optional — you can upload them at the end or send them separately)
Emergency contact name and phone number

What Happens After You Submit

Once you submit this form, a 1st Care Management representative will call you at the phone number
you provide — typically within one business day — to confirm your information, verify your insurance,
and schedule your first in-home visit. If we need any additional documentation, we will let you know
during that call.

Your Information Is Secure

All information submitted through this form is transmitted via secure, encrypted email in compliance
with HIPAA regulations. We take the privacy and security of your health information seriously.

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Patient Intake Form

Please complete all required fields marked with an asterisk (*). If you do not have all information
available right now, complete what you can and our team will gather the rest during your intake call.

Privacy and Security

1st Care Management transmits all information submitted through this form via secure, encrypted emailvto ensure the confidentiality, integrity, and availability of all electronic protected health information (ePHI) in accordance with HIPAA Security Rule requirements under 45 CFR 164.306(a)(1).
We regularly review and update our security measures to maintain reasonable and appropriate protection of all patient data received through this website.
If you have questions about how your information is handled, please contact us at (833) 633-4778 or
email intake@1stcaremanagement.com.