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HOUSE CALL REQUEST FORM & PREAUDIT QUESTIONNAIRE I request a: Standard House Call ($300 value for a copay of $50) Performance House Call ($380 value for a copay of $125) The audit takes about two
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How to fill out house call request form

How to fill out house call request form
01
Open the house call request form.
02
Fill in your contact information such as your name, phone number, and email address.
03
Provide the address where the house call is requested.
04
Specify the date and time you would like the house call to be scheduled.
05
Describe the reason for the house call and provide any additional details or instructions.
06
Review the form to ensure all information is accurate and complete.
07
Submit the form to send your house call request.
Who needs house call request form?
01
Individuals who are unable to visit a doctor's office due to mobility issues.
02
People who prefer the convenience of receiving medical care at home.
03
Patients in need of urgent medical attention but are unable to physically go to a healthcare facility.
04
Elderly individuals who may have difficulty leaving their homes for medical appointments.
05
Individuals with chronic illnesses or disabilities that make it challenging to travel to a doctor's office.
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