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info@rachealhhc.com
1600 Sixth Avenue, suite 116B, York, PA, 17403
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Home
About Us
Services
Pediatrics
Companionship
Personal Care
Skilled Nursing
Careers
Resources
Forms
Contact Us
Blog
Schedule Consultation
Home
About Us
Services
Pediatrics
Companionship
Personal Care
Skilled Nursing
Careers
Resources
Forms
Contact Us
Blog
Schedule Consultation
Intake Information Form
PATIENT INFORMATION
Patient's Name:
Address:
City:
ZIP:
County:
Phone:
DOB:
Sex:
Male
Female
Race:
Marital Status:
INSURANCE INFORMATION
Choose the following:
Admit
Reject
Admitted Date:
MM slash DD slash YYYY
Insurance:
Medicare#:
Untitled
Part A
Part B
Medicaid#:
Social Security Number:
Private Insurance:
PHYSICIAN INFORMATION
Physician Name:
Phone:
NPI:
Address:
City:
ZIP:
HOSPITAL INFORMATION
Hospital Admission Date:
MM slash DD slash YYYY
Hospital Discharge Date:
MM slash DD slash YYYY
Surgical Procedures:
DIAGNOSIS
Primary:
Secondary:
Medications:
Allergies:
Diet:
Equipment Needed:
ICD-10:
Services:
SN
LPN/LVN
HHA
PT
OT
MSW
SLP
Assigned to:
REFERRAL BY
Physician Office:
Hospital:
Others:
Name:
Phone:
Taken By:
Date:
MM slash DD slash YYYY
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