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25%
PATIENT INFORMATION
Primary Care Physician
Patient’s Last Name
First
Middle
Surname
Mr
Miss
Mrs
Ms.
Marital Status (Circle One)
Single
Married
Divorced
Separated
Widow
Widower
Is this your legal name?
Yes
No
If not, what is your legal name?
(Former Name)
Birth Date
Age
Sex
Male
Female
Street Address
City
State
ZIP Code
Social Security
Home Phone No
P.O. Box
City
State
ZIP Code
PETS
Yes
No
Please state the type of PET(S) and Name(s)
Type
Name
INSURANCE INFORMATION
Person Responsible for Bill
Birth Date
Address
Home Phone No
Is this person a patient here?
Yes
No
Occupation
Employer
Employer Address
Employer Phone No.
Is this patient covered by insurance?
Yes
No
Please indicate primary insurance
Subscriber’s Name
Subscriber’s S.S.
Birth Date
Group
Policy
Co-Payment
Patient’s Relationship to Subscriber
Self
Spouse
Child
Other
Other Names of Secondary Insurance (if applicable)
Subscriber’s Name
Group
Policy
Patient’s Relationship to Subscriber
Self
Spouse
Child
Other
IN CASE OF EMERGENCY
Emergency Contact:
Phone
Relationship To Patient
Next
Past Medical History (if known):
Services requested for HHA:
IHSN
Requested start
Does client live alone?
Yes
No
Lives with (Name)
Language(s) spoken
Relationship to patient
Translator needed
Yes
No
Referral Source
Client
Family
Social Worker
Discharge Planner
Doctor
Insurance Co
Physician name
Specialty
Phone
Medical and/or Nursing Diagnosis (if known):
Medications (if known)
Financial
Medicare
Private Insurance
Medicaid HMO
VA
Private Pay
Other
Functional Status (check all that apply):
Mobility
Chair Bound
Bed Bound
Needs assistance with
Ambulation
Transfers
Stairs
Assistive Devices
Walker
Cane
W/C
Shower/tub chair
Commode
ADL’s and IADL’s (Check all that apply)
Needs assistance with
Dressing
Bathing
Grooming
Oral hygiene
Meal prep and cooking
Shopping
Cleaning
Transportation
Drives
Dependent on others
Vision
Glasses
Blind
Legally Blind
Hearing
HOH
Hearing aids
R ear L ear both
Speech
Difficulty speaking
Does not speak
Does not speak or understand English
Alert/Awake/Oriented?
Yes
No
If no, explain
Does client experience Memory Loss?
Yes
No
Confusion
Forgetfulness
Other
Is client incontinent?
Yes
No
If yes, of
Urine
Bowels
Wears disposable
Undergarments
Does client currently have any services in place?
Yes
No
If yes, please explain
Pertinent in information for level of care appropriateness
Notes
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Long Island Medical & Cosmetic Dermatology, P.C. or insurance company to release any information required to process my claims.
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ADVANCE DIRECTIVE ATTESTATION
Client Name
Client Name
Client has an Advanced Directive or POLST form (circle which applies)
Client has been advised to give a copy of Advance Directives to their physician.
Client understands that he/she can make changes to Advance Directives at any time.
Copies of the Advanced Directive or POLST form can be found
Copies of the Advanced Directive/POLST form have been given to
Name
Or
Name
Client does not have a Power of Attorney or Health Care Proxy. (circle one)
Medical decision -making authority has been given by Power of Attorney to
Name
Relationship
Phone number
A copy of the Power of Attorney document
Client does NOT have an Advanced Directive.
Client understands that the home health agency does not require that he/she develop an
Advanced Directive in order to receive care
Federal and state laws regarding Advance Directives have been explained
and materials have been provided about these laws by the Nursing Supervisor
Notes
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PROTECTED HEALTH INFORMATION RELEASE FORM
Client Name
Date
Concerning matters of my health, I give permission to Imperial Caregivers LLC or a member of his staff to speak with
Name of person(s)
Relationship to patient
Email
Phone
Name of person(s)
Relationship to patient
Email
Phone
Name of person(s)
Relationship to patient
Email
Phone
Name of person(s)
Relationship to patient
Email
Phone
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