ICRS Patient Intake Form

Patient Intake Form

New patient intake for Infinite Community Recovery Solutions LLC. Please complete all required fields and any applicable clinical, payment, service, and consent sections.
Patient Demographics
Admission Date

MonthDayYear
Date
Service Type
Patient Full Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Social Security # (Last 4)
Home Address Prior to Admission

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Language
Emergency Contact
Emergency Contact Full Name

First NameMiddle NameLast Name
Emergency Contact Relationship to Patient
Emergency Contact Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referring Provider and Discharge Information
Referring Physician / Provider Name
Facility / Hospital Name
Discharge Planner / Case Manager
Discharge Date

MonthDayYear
Date
Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider Fax
Please enter a valid phone number.Format: (000) 000-0000.
Primary Diagnosis / Condition
ICD-10 Code(s)
Discharge Summary Attached
Payment and Billing Information
Payment Method
If Other Payment Method, Specify
Responsible Party Name
Responsible Party Relationship to Patient
Responsible Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Email
example@example.com
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Sponsoring Hospital / Facility Name
Authorizing Department
Authorization Contact Name
Authorization Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Purchase Order / Auth Number
Authorized Amount
Billing Instructions / Special Notes
CARE TRACK & CLINICAL DETAILS
Clinical Services Needed

Other
If Other or Combined Care Track, describe
IV / PICC Line Details (complete if applicable)
Type of IV Access:
Antibiotic / Medication Name:
Infusion Frequency:
Expected Duration of Treatment:
Home Health Agency Assigned:
HHA Contact Phone:
ICRS Staff PICC Monitoring Role (non-medical observation only):

Other
Home Health Agency Performing Clinical PICC Care:
HHA / Visiting Nurse Agency Name:
Nurse / Clinician Contact Name:
HHA Phone:
Scheduled Visit Days & Times:
Cosmetic / Aesthetic Procedure Recovery Details (complete if applicable)
Performing Surgeon / Provider Name:
Performing Facility / Clinic:
Provider Phone:
Procedure Date:
Procedure(s) Performed:
Procedure Type (check all that apply):

Other
If Other, specify procedure:
Surgical Drains Present?
Compression Garment Required?
Lymphatic Massage Ordered?
Post-Op Instructions / Restrictions Attached?
Surgeon Post-Op Follow-Up Date:
Surgeon Follow-Up Location:
Functional / Mobility Status:
Current Medications:
ADD-ON SERVICES (OPTIONAL)

The following supportive services are available as optional add-ons to your residential care plan. Check all services you wish to enroll in. A service agreement and rate confirmation will be provided prior to activation.
TRANSPORTATION SERVICES
PERSONAL CARE & HYGIENE
COSMETIC RECOVERY SPECIALIZED SERVICES
MEALS & NUTRITION
HOUSEKEEPING & LAUNDRY
WELLNESS & COMFORT
CARE COORDINATION
Additional Requests / Special Accommodations:
CONSENTS & ACKNOWLEDGEMENTS

By signing below, the patient (or authorized representative) acknowledges and agrees to the following:
HIPAA NOTICE & PRIVACY ACKNOWLEDGEMENT
I acknowledge that I have received or been offered a copy of the ICRS Notice of Privacy Practices, which describes how my health information may be used and disclosed.
Signature

Patient / Authorized Representative Signature:
Signature

ICRS Staff / Intake Coordinator Signature:
Printed Name: _______________________

Date: ______________________________

Relationship (if not patient): ____________
Printed Name: _______________________

Date: ______________________________

Title: ______________________________
Should be Empty:

Patient Intake Form

Patient Demographics

Emergency Contact

Referring Provider and Discharge Information

Payment and Billing Information

CARE TRACK & CLINICAL DETAILS

Cosmetic / Aesthetic Procedure Recovery Details (complete if applicable)

ADD-ON SERVICES (OPTIONAL)

CONSENTS & ACKNOWLEDGEMENTS