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INTAKE FORM
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PATIENT INFORMATION
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Name
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Date of Birth
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Phone Number
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Gender
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Address
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Race
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Preferred Language
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INSURANCE INFORMATION
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Insurance ID #
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Others (please specify)
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Preferred MD
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REASON FOR EVALUATION
• • •
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Hospital Name
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Date of Discharge
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Patient using Other (please specify)
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Other Reason (please specify)
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Additional Comments
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REFERRED FACILITY/ HOME HEALTH CARE
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Name of Facility / Home Health
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Contact Person (if any)
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Phone #
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Email
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Fax #
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Address
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For ARTEMIS MEDICAL CENTER office use only
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Eligibility
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Note
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Date Scheduled for Visit
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Provider Name
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