ÿþ<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" /> <meta http-equiv="imagetoolbar" CONTENT="no" /> <title>Recovery Home Care - Serving South Florida, Central Florida and the Treasure Coast</title> <link href="rhc.css" rel="stylesheet" type="text/css" /> <script type="text/javascript" src="menu.js"></script> <script type="text/javascript" src="js/flashobject.js"></script> <script type="text/javascript" > function validate(){ if(!document.doctorRequestService.emailTF.value){ alert("Please submit your email address."); return false; } } </script> </head> <body> <div id="container"> <div id="container"> <div id="header"> <div id="flashcontent"> You don't have the lastest Flash Plugin installed. </div> <script type="text/javascript"> // <![CDATA[ var fo = new FlashObject("homeHeader.swf", "homeHeader", "759", "175", "7.0.19.0", "#FFFFFF", false); fo.write("flashcontent"); // ]]> </script> </div> <div id="menu"> <?php include("menu.php"); ?> </div> <div id="content"> <h1 class="subHead">Request for Services</h1> <p>Please fill out as much as you re comfortable with, and a Recovery Home Care representative will contact you shortly</p> <form id="doctorRequestService" name="doctorRequestService" method="post" action="docReqSvc_process.php" onsubmit="return validate()"> <table width="462" border="0" cellpadding="2" cellspacing="2" id="subTable"> <tr> <td width="253"><p>Person Requesting Services </p></td> <td width="195"><p> <input name="nameRS" type="text" id="nameRS" /> </p></td> </tr> <tr> <td width="253"><p>Phone Number: </p></td> <td width="195"><p> <input name="phone" type="text" id="phone" /> </p></td> </tr> <tr> <td width="253"><p>Patient's Name: </p></td> <td width="195"><p> <input name="nameTF" type="text" id="nameTF" /> </p></td> </tr> <tr> <td width="253"><p>Patient's Phone: </p></td> <td width="195"><p> <input name="phone2" type="text" id="phone2" /> </p></td> </tr> <tr> <td><p>Address 1: </p></td> <td><p> <input name="addressTF" type="text" id="addressTF" /> </p></td> </tr> <tr> <td><p>Address 2: </p></td> <td><p> <input name="address2TF" type="text" id="address2TF" /> </p></td> </tr> <tr> <td><p>City:</p></td> <td><p> <input name="cityTF" type="text" id="cityTF" size="15" /> </p></td> </tr> <tr> <td><p>State:</p></td> <td><p> <select name="stateTF" id="stateTF"> <option value="SELECT" selected="selected">SELECT</option> <option value="AL">AL</option> <option value="AK">AK</option> <option value="AS">AS</option> <option value="AR">AR</option> <option value="CA">CA</option> <option value="CO">CO</option> <option value="CT">CT</option> <option value="DE">DE</option> <option value="DC">DC</option> <option value="FL">FL</option> <option value="GA">GA</option> <option value="HI">HI</option> <option value="ID">ID</option> <option value="IL">IL</option> <option value="IN">IN</option> <option value="IA">IA</option> <option value="KS">KS</option> <option value="KY">KY</option> <option value="LA">LA</option> <option value="ME">ME</option> <option value="MD">MD</option> <option value="MA">MA</option> <option value="MI">MI</option> <option value="MN">MN</option> <option value="MS">MS</option> <option value="MO">MO</option> <option value="MT">MT</option> <option value="NE">NE</option> <option value="NV">NV</option> <option value="NH">NH</option> <option value="NJ">NJ</option> <option value="NM">NM</option> <option value="NY">NY</option> <option value="NC">NC</option> <option value="ND">ND</option> <option value="OH">OH</option> <option value="OK">OK</option> <option value="OR">OR</option> <option value="PA">PA</option> <option value="RI">RI</option> <option value="SC">SC</option> <option value="SD">SD</option> <option value="TN">TN</option> <option value="TX">TX</option> <option value="UT">UT</option> <option value="VT">VT</option> <option value="VA">VA</option> <option value="WA">WA</option> <option value="WV">WV</option> <option value="WI">WI</option> <option value="WY">WY</option> </select> </p></td> </tr> <tr> <td><p>Zip:</p></td> <td><p> <input name="zipTF" type="text" id="zipTF" size="10" maxlength="5" /> </p></td> </tr> <tr> <td><p>Email:</p></td> <td><p> <input name="emailTF" type="text" id="emailTF" size="25" /> </p></td> </tr> <tr> <td><p>D.O.B.</p></td> <td><p> <input name="dobTF" type="text" id="dobTF" size="15" maxlength="8" /> </p></td> </tr> <tr> <td><p>Social Security #:</p></td> <td><p> <input name="socialTF" type="text" id="socialTF" size="15" maxlength="9" /> </p></td> </tr> <tr> <td><p>Medicare #:</p></td> <td><p> <input name="medicareTF" type="text" id="medicareTF" /> </p></td> </tr> <tr> <td><p>County Where Services will be Performed:</p></td> <td><p> <select name="countiesTF" id="countiesTF"> <option value="SELECT" selected="selected">SELECT</option> <option value="BROWARD">BROWARD</option> <option value="INDIAN RIVER">INDIAN RIVER</option> <option value="LAKE">LAKE</option> <option value="MARION">MARION</option> <option value="MARTIN">MARTIN</option> <option value="OKEECHOBEE">OKEECHOBEE</option> <option value="PALM BEACH">PALM BEACH</option> <option value="SUMTER">SUMTER</option> <option value="ST. LUICE">ST. LUICE</option> </select> </p></td> </tr> <tr> <td><p>Insurance:</p></td> <td><p> <input name="insuranceName" type="text" id="insuranceName" /> </p></td> </tr> <tr> <td><p>Insurance ID:</p></td> <td><p> <input name="insuranceidTF" type="text" id="insuranceidTF" /> </p></td> </tr> <tr> <td><p>Insurance Address 1:</p></td> <td><p> <input name="insuranceAddressTF" type="text" id="insuranceAddressTF" /> </p></td> </tr> <tr> <td><p>Insurance Address 2:</p></td> <td><p> <input name="insuranceAddress2TF" type="text" id="insuranceAddress2TF" /> </p></td> </tr> <tr> <td><p>Insurance Phone:</p></td> <td><p> <input name="insurancePhone" type="text" id="insurancePhone" /> </p></td> </tr> <tr> <td><p>Diagnosis:</p></td> <td><p> <input name="diagnosisTF" type="text" id="diagnosisTF" /> </p></td> </tr> <tr> <td><p>Physician Name:</p></td> <td><p> <input name="physicanNameTF" type="text" id="physicanNameTF" size="15" /> </p></td> </tr> <tr> <td><p>Physician Phone:</p></td> <td><p> <input name="physicianNumberTF" type="text" id="physicianNumberTF" size="15" /> </p></td> </tr> <tr> <td><p>Service(s) Requested: </p></td> <td><p>&nbsp;</p></td> </tr> <tr> <td><p> <input name="serviceRequested[]" type="checkbox" id="serviceRequestedTF" value="RN Eval &amp; Tx" /> RN Eval &amp; Tx <br /> <input name="serviceRequested[]" type="checkbox" id="serviceRequested2TF" value="PT Eval &amp; Tx" /> PT Eval &amp; Tx <br /> <input name="serviceRequested[]" type="checkbox" id="serviceRequested3TF" value="OT Eval &amp; Tx" /> OT Eval &amp; Tx <br /> <input name="serviceRequested[]" type="checkbox" id="serviceRequested4TF" value="ST Eval &amp; Tx" /> ST Eval &amp; Tx <br /> </p></td> <td><p> <input name="serviceRequested[]" type="checkbox" id="serviceRequested5TF" value="HHA" /> HHA <br /> <input name="serviceRequested[]" type="checkbox" id="serviceRequested6TF" value="MSW" /> MSW <br /> <input name="serviceRequested[]" type="checkbox" id="serviceRequested7TF" value="Medical Equipment" /> Medical Equipment </p></td> </tr> <tr> <td><p>Frequency Duration:</p></td> <td><p> <input name="frequencyDurationTF" type="text" id="frequencyDurationTF" /> </p></td> </tr> <tr> <td><p>Orders/Notes:</p></td> <td><p> <textarea name="ordersTF" id="ordersTF"></textarea> </p></td> </tr> <tr> <td><p>&nbsp;</p></td> <td><p>&nbsp;</p></td> </tr> <tr> <td colspan="2"><div align="center"> <input type="submit" name="Submit" value="Submit" /> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="reset" name="Submit2" value="Reset" /> </div></td> </tr> </table> </form> <p class="subHead">&nbsp; </p> </div> <div id="rightColumn"> <!--- News Feed Module ---> <?php include("NewsFeedMod.php"); ?> <!--- News Feed Module ---> </div> <div id="footer"> <?php include("copyright.php"); ?> </div> </div> <script type="text/javascript"> var gaJsHost = (("https:" == document.location.protocol) ? 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