Medical Intake - OCR Wizard

Step 1/4
1Upload
2Extract
3Form
4Recheck

Step 1: Upload Document

Upload one or more images or PDFs of the form.

📂 Drag & drop or choose multiple files

Step 2: Extract Documents

We will scan your document and extract text.

Loading...

Waiting to start...

Step 3: Patient & Insurance Information

Patient Information

Patient Insurance Information

Diagnosis

Eligibility & Benefits

Insurer Information

Referring Provider

Physicians Order Recommendation


Wounds

POD (Proof of Delivery)

Product Item # Size Code Quantity
Collagen Sheet CD-1010 1x1 A6021
Collagen Sheet CD-2020 2x2 A6021
Collagen Sheet CD-4040 4x4 A6021
Collagen Sheet CD-7070 7x7 A6023
Collagen Sheet CD-0510 5x10 A6023
Collagen Powder CP-1010 1 Gram A6010
3x3
7x12
9x9

Intake Sheet

Product Item # Size Code QTY of Boxes Office Use Only
Collagen Sheet CD-1010 1x1
30 units per box
A6021
Collagen Sheet CD-2020 2x2
30 units per box
A6021
Collagen Sheet CD-4040 4x4
30 units per box
A6021
Collagen Sheet CD-7070 7x7
15 units per box
A6023
Collagen Sheet CD-0510 5x10
15 units per box
A6023
Collagen Powder CP-1010 1 Gram
30 units per box
A6010
Size QTY Office Use Only
3x3
A6012 Code
5 units per box / for powder and 1x1 Collagen Sheet
7x12
A6012 Code
5 units per box / for 5x10 Collagen Sheet
9x9

Step 4: Review & Submit

Please review your details before submission:

Medical Insurance Verification-Best Practice

Complete every field exactly as shown — all text preserved.

PATIENT INFORMATION

PATIENT INSURANCE INFORMATION

Diagnosis

PATIENT ELIGIBILITY AND BENEFITS INFORMATION

INSURER INFORMATION

REFERRING PROVIDER INFORMATION

Physicians Order Recommendation

MEDICARE PT CAN NOT BE CURRENTLY RECEIVING HOMECARE (PT, OT, HHA NURSE)
Wound 1:
x x
x x
x x
x x
Wound 1:
x x
x x
x x
x x
Stage 1: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin
Stage 2: Partial-thickness skin in the subcutaneous tissue/dermis
Stage 3: Full-thickness loss of skin through fascia/muscle
Stage 4: Full-thickness skin/dermis
All materials and supplies were dispensed upon the patient's needs. Home Instructions were reviewed and all questions were answered in detail.
(Please see attached prescription and patient relations statement of receipt)
Product Name #SizeCollagen Sheet
CD-10101x1A6021
CD-20202x2A6021
CD-40404x4A6021
CD-101110x10A6023
CD-70707x7A6023
CD-05105x10A6023
CD-102010x20A6023
CP-101GramA6010(Collagen Powder)

Proof of Delivery (POD)

Product Item #SizeCodeQty
CD-10101x1A6021
CD-20202x2A6021
CD-40404x4A6021
CD-70707x7A6021
CD-90909x9A6021
CP-101010cmA6030
Secondary DressingsQty
3x3
7x12
9x9
I acknowledge receipt of the products identified here and understand that a manufacturer and not our company delivers, a two-year manufacturer's warranty covers the products against material defects. We will provide free repair or replacement for items under warranty. Any issues must be reported within 3 days. The medical supplies delivered are to be used only by the person identified and for the treatment of their specific diagnosis...

Intake Sheet

ProductItem #SizeCodeQTY of BoxesOffice Use Only
Collagen SheetCD-10101x1 (10 units/box)A6021
CD-20202x2 (20 units/box)A6021
CD-40404x4 (20 units/box)A6021
CD-70707x7 (10 units/box)A6021
CD-85708.5x7 (15 units/box)A6025
Collagen PowderCP-101010cm (1 box)A6030
Secondary DressingsQtyOffice Use Only
3x3 A6012
7x12 A6012
I acknowledge and understand all of the above by typing my name below.