Patient Demographic Intake Form - HCCIntelligence™ Premier Resource 2024-Premier Resource: Patient Demographic Intake Form

Premier Resource: Patient Demographic Intake Form - 2024

Pdf Summary

This document is a demographic intake form that collects information about a patient. It includes sections for patient information, primary insurance information, emergency contact information, other information, secondary insurance information, and responsible financial party information.<br /><br />The patient information section collects details such as the patient's name, address, facility/complex and room number, city, state, zip code, primary and secondary phone numbers, birth date, social security number (helpful for billing purposes), marital status, race, ethnicity, and whether the patient lives alone or not.<br /><br />The primary insurance information section asks for information about the patient's insurance company, subscriber name and birth date, group number, policy/ID number, and claims address.<br /><br />The emergency contact information section collects details about two emergency contacts, including their names, relationship to the patient, primary and secondary phone numbers, and whether they can be contacted regarding visits/times/etc and medical results/advice.<br /><br />The other information section asks the patient how they heard about the facility, whether they have home health care, the name and phone number of the agency providing home health care, and whether they have durable medical equipment in their home.<br /><br />The secondary insurance information section is similar to the primary insurance information section and asks for details about the patient's secondary insurance company, subscriber name and birth date, group number, policy/ID number, and claims address.<br /><br />The responsible financial party information section collects details about the person responsible for the patient's financial arrangements, including their name, address, city, state, zip code, primary and secondary phone numbers, and their relationship to the patient.<br /><br />Finally, there is a space to provide information about the current/previous primary care provider, including their name, phone number, fax number, practice name, address, and email.<br /><br />This document was developed by the Home Centered Care Institute.

Keywords

demographic intake form

patient information

primary insurance information

emergency contact information

other information

secondary insurance information

responsible financial party information

insurance company

emergency contacts

home health care