Intake Form
Type of Facility
*
Group Home
Indepenadnt Living
Assisted Living
Private Home
Other
Facility Name
*
Patient Name
*
First Name
Last Name
Date of Birth
*
SSN
*
Primary Insurance
*
ID
Group Number
Secondary Insurance
ID
Group #
Marrital Status
Single
Married
Divorced
Widow
Group Home E-mail
example@example.com
Group Home Phone Number
*
-
Area Code
Phone Number
Group Home/ Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy
Name
Number
Can You (Patient) Make Your Own Decisions
*
Yes
No
Do You (Patient) Have a Current Living Will
*
Yes
No
Do You (Patient) Have an Advanced Directive
*
Yes
No
Do You (Patient) Have a POA
*
Yes
No
Name Of POA
First Name
Last Name
POA Phone Number
Please enter a valid phone number.
Provide all Preious Care Providers
PCP
Name
Number
Urology
Name
Number
Cardiology
Name
Number
Neurology
Name
Number
Last hospitalization
Name
Number
Last Rehab
Name
Number
Home Health
Name
Number
Are You (Patient) Currently Enrolled in Hospice?
*
Yes, I am currently enrolled in hospice
No, I have never been enrolled in hospice
No, but I have been enrolled
Last Hospice
Name
Number
Insurance Card Front and Back Upload
*
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Medication List
*
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Consent to Release Medical Information I hereby authorize Oasis House Call and its authorized staff to release and disclose my protected health information (PHI), including but not limited to medical records, treatment plans, test results, and diagnostic reports, to any referring or consulting physicians, specialists, or healthcare providers involved in my care. This authorization is given in compliance with all applicable federal and state privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA).I understand that this information will only be shared as necessary to coordinate my treatment, facilitate referrals, or ensure continuity of care. I release Nicole Oprea, its agents, and employees from any liability arising from the authorized use or disclosure of my medical information as outlined above. This consent remains valid for the duration of my treatment unless revoked in writing.
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