Get Patient Intake Form - Reginfo

Completing the Patient Intake Form - Reginfo is an essential step in the enrollment process for participants in the Patient Navigator Outreach and Chronic Disease Prevention Program. This guide will provide clear and supportive instructions on how to fill out the form online to ensure that all necessary information is accurately captured.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the Patient Intake Form and open it for editing.
2. Begin with the 'Demographics' section. Fill in your gender by selecting one of the options: Male, Female, or Transgender. Also, enter your 3-digit zip prefix and birth year, ensuring that the birth year is in the four-digit format.
3. Next, provide information regarding your household. Enter the household size and select your ethnicity from the available options.
4. In the 'Race' section, check all categories that apply to you. If you prefer a specific language, indicate your primary/preferred language from the provided list.
5. Proceed to the 'Navigated Condition(s)' area and indicate if you would like to refuse this section.
6. Fill out the 'Education' section by selecting your highest level of education completed. This information is required for registration purposes.
7. In the 'Household Income' section, select the income range that best represents your household’s financial status. Additionally, be prepared to answer the questions regarding past hospital stays and ER visits.
8. For the 'Coverage' section, indicate whether you have pharmacy assistance and check all applicable healthcare coverage options.
9. If applicable, complete the health conditions section by checking any conditions that apply to you, filling out diagnosis details and dates as needed.
10. Finally, review all the information you entered. Once you are satisfied, you can save the changes, download the form, print it, or share it as needed.

Complete the Patient Intake Form - Reginfo online to ensure your participation in the program.