Get Hospital Preference Form2019.docx

The Hospital Preference Form2019.docx is an essential document that allows you to specify preferred hospitals for emergencies. This guide provides clear, step-by-step instructions on how to complete the form effectively online, ensuring your preferences are recorded accurately.

Follow the steps to complete your Hospital Preference Form online.

1. Click the ‘Get Form’ button to access the Hospital Preference Form2019.docx and open it in your preferred editing tool.
2. Begin by entering the full name of the client in the designated field, which appears after 'Mr./Ms./Mrs.' This section is crucial as it identifies the individual for whom the form is being filled out.
3. Next, indicate the preferred hospital for emergencies by placing an initial next to your choice. You have two options: Tallahassee Memorial Hospital (TMH) or Capital Regional Medical Center (CRMC). Make sure to only initial one option.
4. Fill out the insurance policy information. Provide the name of the insurance company in the designated field, followed by the policy number, member number, and group number in the appropriate fields.
5. If you have a secondary insurance, repeat the same process by filling in the details for the secondary insurance policy, including the policy, member, and group numbers.
6. The client must sign the form where indicated to confirm their preferences. Ensure that the signature is clear and legible.
7. Next, enter the date of signing in the designated field below the client’s signature.
8. Provide the name of the guardian, family member, or caregiver responsible for the client in the specified section. This ensures proper documentation and accountability.
9. Indicate the name of the TMH Adult Day Care Program Coordinator in the space provided to complete the form. This is important for the coordination of care.
10. Finally, fill in the contact phone number for the caregiver or guardian, followed by the date in the respective fields. After completing all sections, ensure to save your changes, and consider downloading or printing the form for your records or sharing it as needed.

Complete your Hospital Preference Form online to ensure your preferences are recorded and communicated effectively.