Get Resident Personal Data Form - New York State Department Of Health - Health Ny

Filling out the Resident Personal Data Form is an essential step for residents in assisted living facilities in New York State. This guide provides clear, step-by-step instructions to help users complete the form online and ensure that all necessary information is accurately submitted.

Follow the steps to successfully complete the Resident Personal Data Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling in the resident's name and the facility name at the top of the form.
3. In the Admission / Discharge Information section, provide the date of admission, county, and where the resident was admitted from, selecting the appropriate option and specifying if necessary.
4. Fill out the address the resident was admitted from, including street, city, state, and zip code, and indicate the discharge date.
5. Specify where the resident is discharged to and provide the corresponding address if applicable.
6. In the Personal Data section, enter the resident's date of birth and select the gender option.
7. Provide emergency contact information, including name, relationship, home, work, and cell phone numbers, along with their address.
8. Indicate the marital status of the resident by selecting one of the options.
9. List any other health care providers, including their names, specialties, and contact information.
10. Include the attending physician's information in the designated section.
11. Complete the Health Insurance and Pharmacy sections with the relevant details regarding coverage and medications.
12. In the Personal Background section, complete information such as how the resident wishes to be addressed, their representative, significant other, and any additional personal information.
13. Final sections include any living will, power of attorney, or health care proxy designations. Ensure all sections are completed accurately.
14. Once all information is filled out, save changes, and choose whether to download, print, or share the form as needed.

Complete your documents online for a seamless submission process.