Get Inpatient Admission Form - Chpw.org

Completing the Inpatient Admission Form online is an essential step in ensuring proper admission procedures for patients. This guide provides clear instructions on how to navigate each section of the form effectively.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Fill in the facility information section which includes the hospital name, contact name, today's date, phone number, fax number, tax ID, and NPI.
3. Provide the patient information, including the first name, last name, CHPW member ID, date of birth, middle initial, and the plan/program associated with the patient. If applicable, include the retro enrollment date.
4. In the admission information section, specify the admit date, admit time, admit type (choose from planned, urgent, or emergent), discharge date, admitting physician, and admitting diagnosis.
5. If applicable, complete the newborn information section. This includes the sex, date of birth, first name of the newborn, delivery type (vaginal or C-section), bed type (regular nursery or special care nursery/NICU), attending pediatrician's last name, and middle initial.
6. Review all the provided information for accuracy and completeness before submitting the form.
7. Once satisfied with the form, save the changes, and you may choose to download, print, or share the completed form as needed.

Start completing your Inpatient Admission Form online today for a smooth admission process.