New Patients

Patients that have not yet set up an account with The Pouch Place, Inc. will need to complete and submit thePatient Information Form and New Patient History Form (Ostomy, Urological, Wound Care) that applies to you. We also ask that you review the information listed under Online Forms then review and submit the Orientation Checklist. Please review the insurance companies that we work with to be sure that we will be able to bill your insurance.

Make copies of your insurance cards (front and back) and email, fax , or mail the copies. We will then email or fax an ASSIGNMENT OF BENEFITS form which requires acknowledgement from you prior to dispensing your first order.