APPRISE Screening Intake Form – Blair Senior Services

APPRISE Screening Intake Form

APPRISE Medicare Beneficiary Screening Intake Form

Step 1 of 4

Current Medical Providers
Primary Care Information
Primary Care Provider Practice Name & Location
Specialist Information
Specialist Practice Name & Location

Click the "+" to add another Specialist(up to 5)
Hospital Information
Hospital Location

Click the "+" to add another Hospital(up to 2)
Other Providers (Example: DME)
Provider Address

Click the "+" to add another Provider(up to 2)

List of Current Medications
Current Medications
Medication Name Doasge Frequency Type (Brand or Generic)

Click the "+" to add another Medication(up to 15)

Pharmacy Information
Current Pharmacy
Pharmacy Location
Would you consider using another pharmacy if your prescription costs are lower?
- Yes
- No
Would you consider using mail order?
- Yes
- No
Would you consider using mail order?
- Yes
- No
Notes
Name
This field is for validation purposes and should be left unchanged.

Blair Senior Services, Inc. serves residents of all ages through diverse programming and in Senior Centers in Blair County and surrounding areas.

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1320 12th Avenue
Altoona, PA 16601
1-800-245-3282
814-946-1235
Monday - Friday
8 am - 4 pm

Blair Senior Services, Inc. helps local older adults live long, independent lives every day. You too can help an older adult remain at home today!