SHADOWNURSE Email Marketing -

Care Navigation - Senior Priority Referral
From: Dr. Vishal Banthia
To: ShadowNurse, Inc

Required Info

Pt's First Name *

Pt's Last Name *

Date of Birth *

Pt's Phone *

Pt's Email *

Pt's State *

Care Navigation Qualifier

____________

-- If available --

Pt's Insurance Member ID / Medicare Beneficiary ID

____________

Provider Information

Provider First Name *

Provider Last Name *

Provider Title *

____________

Last Step: Provider Authorization

What arrangement gives you authority to act for this patient?

Provider Authority *

The patient is present and consents now

I obtained prior verbal consent and documented it in the chart

Disclosure is permitted for treatment/operations with clinical partner coordination (TPO under HIPAA)

By submitting this referral, I attest I am the treating/ordering provider (or staff acting under direction) and that the patient has agreed to be contacted by ShadowNurse. I authorize ShadowNurse to verify Medicare eligibility/benefits and coordinate scheduling/referrals with independent clinical partners; this does not assign benefits to ShadowNurse.

To view the full policy, please visit https://www.shadownurse.com/authorized-representative-consent

Medicare Eligibility & Benefits Authorization

“I authorize Medicare eligibility/benefits verification.” *

Selecting the checkbox and opting in provides consent to receive text messages from ShadowNurse, Inc. related to care navigation services, appointment reminders, and service updates. No marketing SMS will be sent without separate, express written consent. Consent is not a condition of purchase. Msg & data rates may apply, delivery is not guaranteed, and frequency varies. Reply STOP to opt out; HELP for help. To resume, reply START. Get support at (833) 2-SHADOW or hello+SMS@shadownurse.com. (Visit https://www.shadownurse.com/policies)