Follow the steps to easily complete the form online.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred online platform for editing.
2. Begin by entering the facility name and city in the respective fields. Provide your name and select whether you are completing this form as a skilled professional, non-skilled professional, Medicaid representative, or hospice provider. Include your phone number and direct contact cell for text updates.
3. Fill in the primary insurance name and number for the patient, along with the patient's name, date of birth, sex, height, and weight.
4. Input the name of the ordering physician (first and last names are required) and the date of the consultation.
5. Indicate the primary medical reasons for the consult by checking all applicable symptoms listed, such as coughing, difficulty swallowing, or risk of aspiration.
6. Describe any status changes in the patient’s condition, including improvements or declines in symptoms. Check the appropriate patient swallowing status as either BETTER or WORSE, considering the symptoms provided.
7. Select the patient’s current diet and liquid intake, and detail any communication abilities. Include pertinent medical history and current treatments.
8. Review and complete the order portion of the form; include necessary assessments indicated for the dysphagia consultation.
9. Check reasons for requiring a mobile or onsite visit, selecting any that apply.
10. Ensure to provide a signature in the designated area, with credentials circled as necessary to validate the verbal order.
11. Document whether verbal consent was received from the patient or legal guardian, marking the appropriate section.
12. Once all sections are completed, ensure to save any changes made to the form. You may also choose to download, print, or share the document as needed.

Take the next step towards a successful consultation by completing your Facility Intake Form online today.