Get Farewell To Falls Application Form - Sccfd

The Farewell To Falls Application Form - Sccfd is an essential document aimed at facilitating referrals to the fall prevention program for seniors. This guide provides a detailed, step-by-step approach to completing the form online, ensuring clarity and ease for all users.

Follow the steps to fill out the Farewell To Falls Application Form - Sccfd online.

1. Click the ‘Get Form’ button to access the Farewell To Falls Application Form - Sccfd and open it in your preferred editor.
2. Begin by entering the participant's name in the designated fields labeled 'Last' and 'First.' Make sure to spell the name accurately to avoid any discrepancies.
3. Input the participant's date of birth in the format MM/DD/YYYY. This information is critical for proper identification.
4. Fill in the Medical Record Number (MRN) if applicable. This number is used to track participant's medical history at Stanford Hospital and Clinics.
5. Record today's date and the time of filling out the form. This helps maintain accurate records and timelines.
6. Provide the participant's phone number in the specified format. Ensure that it is a number where they can be easily reached.
7. Select the participant's sex by indicating either 'Male' or 'Female.' This is part of the demographic information collected.
8. Indicate if a translator is needed by checking 'Yes' or 'No.' If 'Yes,' specify the language required.
9. Complete the participant's address, including the city, state, and zip code. This is necessary for any follow-up communications.
10. Provide a description of the fall, including details that may assist in the referral process to the fall prevention program.
11. Answer whether the participant has been a patient of Stanford Hospital and Clinics by selecting 'Yes' or 'No.'
12. Participants must authorize the sharing of their personal information for referral by signing their name in the designated area.
13. Indicate who referred the participant by filling out the name and selecting the appropriate agency, such as 'Fire/Paramedic' or 'Primary Care Physician.'
14. After filling out all sections, review the information for accuracy, then save your changes, download the form, or print it for sharing.

Complete the Farewell To Falls Application Form - Sccfd online today to facilitate your referral.