Patient Intake Sheet
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Middle Name
Suffix
Marital Status
Please Select
Single
Married
Divorced
Legally separated
Widowed
Date of Birth
-
Month
-
Day
Year
Date
Sex
Please Select
Male
Female
N/A
Patient Physical Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number:
Format: (000) 000-0000.
Alternate Phone Number:
Format: (000) 000-0000.
E-mail
example@example.com
Do you consent to receiving electronic correspondence via email/text regarding patient:
Yes
No
Caretaker Information
Name
First Name
Last Name
Relationship to Patient
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Do you consent to receiving electronic correspondence via email/text regarding patient:
Yes
No
Please list it here
Emergency Contact
Emergency Contact:
First Name
Last Name
Relationship
Contact Number
Format: (000) 000-0000.
Insurance
Primary Insurance
Insurance Type
HMO
PPO
Group ID
Policy Number
Eligibility and Verification
Date
-
Month
-
Day
Year
Date
Reference Number
Agent Name
First Name
Last Name
Patient Eligibility
Effective Date
-
Month
-
Day
Year
Date
Has deductible been satisfied?
Yes
No
Amount Remaining
Secondary Insurance
Policy Number
Prior Authorization
Number of Visits Approved
Consent to Treat
Does Advanced Practice House Calls have patient consent to assess and treat?
Yes
No
Chronic Care Management Consent: We encourage you to participate in the Chronic Care Management (CCM) program. Chronic Care Management (CCM) services help manage your health between office visits. The program provides a series of rpm-face-to-face activities and additional services especially for our CCM patients. You will have a dedicated Care Team that is familiar with your conditions - We actively help you manage all your medications - We help coordinate your care with your other doctors - We share your health information only with other authorized providers. Each month, after we provide you with a minimum of 20 minutes of non-face-to-face services, we will bill your insurer(s). Either you or your supplementary insurer may be responsible for any deductible or co-pay. DOES ADVANCED PRACTICE HOUSE CALLS HAVE PATIENT CONSENT FROM THE PATIENT TO PROVIDE CHRONIC CARE MANAGEMENT SERVICE?
Yes
No
For Transitional Care Management
Patient Discharge Date form Hospital/Rehab
-
Month
-
Day
Year
Date
Patient contacted 2 days after discharge: 1st attempt
Patient contacted 2 days after discharge: 2nd attempt
Is patient establishing with us as PCP (Y/N)?
Yes
No
If the patient will only be seen for transitional visits, who is the patient's PCP?
PCP Phone
Please enter a valid phone number.
Format: (000) 000-0000.
PCP Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Health History
Primary Diagnosis
Other Health Concerns
Pharmacy
Pharmacy Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies
NKDA
Dialysis
Yes
No
Dialysis Days
Home Bound Status
Do you use an Assistive Device? If so, what kind? (Wheelchair, Walker, Cane)
Do you require assistance by another person to leave your home?
Please list any complex and multiple medical, psychiatric and social problems.
Disabled
Yes
No
Too sick and cannot make it to doctors clinic.
Yes
No
Please select if you need one of the following:
Please Select
Intermittent skilled nursing care
Physical Therapy
Speech Therapy
Occupational Therapy
Something Else
Other Pertinent Information
Referral Source:
Date Referral Received
-
Month
-
Day
Year
Date
Home Health Company Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
Please enter a valid phone number.
Format: (000) 000-0000.
Date Patient Scheduled
-
Month
-
Day
Year
Date
Provider
Person Completing Intake Form
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
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Continue
Should be Empty: