Insurance box, include the name of the resident’s primary insurer, the resident’s insurance ID number, Medicaid and/or Medicare numbers (if appropriate), the name of any prescription drug plan in which the resident is a member, any associated ID numbers, as well as any other health care insurance coverage that the resident might have. In addition, include the name, phone number, and address of any pharmacy with which the resident does business. In the Area Hospital/Clinic of Choice box, incl.
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How to fill out the DOH-4397 online
The DOH-4397 form, consisting of the ALR Resident Personal Data Form Part A and the ALR Resident Evaluation Form Part B, is essential for documenting necessary information regarding individuals prior to their admission to an Assisted Living Residence. This guide provides clear instructions on how to complete the form online, ensuring accuracy and compliance with the requirements.
Follow the steps to successfully complete the DOH-4397 online.
- Press the ‘Get Form’ button to access the online version of the form in your preferred document editor.
- Begin with Part A, the ALR Resident Personal Data Form. Fill out Section I: Personal Data by entering the resident’s date of birth, gender, marital status, and emergency contact information. Make sure to gather this information through an interview with the resident or their family.
- In the Health Insurance section, input the resident’s primary health insurer's name and relevant identification numbers, including Medicaid or Medicare, if applicable. Ensure to include the pharmacy details the resident utilizes.
- Proceed to Section II: Personal Background. Obtain and fill in the resident's social, residential, and occupational/educational information. Take the time to address how the resident wishes to be identified.
- Complete the ALR Resident Evaluation Form Part B by starting with Section 1: Communication/Dental/Vision/Hearing. Collect information on the resident's ability to communicate, their dental and sensory impairments, if any.
- Continue to Section 2: Customary Routine. Document the resident’s preferences in terms of daily activities such as sleeping, bathing, and eating habits based on conversations with them or their support network.
- In Section 3: Continence Status/Management, assess and record the resident's continence status for both bowel and bladder. Refer to prior medical evaluations for accurate information.
- Section 4: Physical Function requires information about the resident’s ability to perform daily living activities. Gather this data through interviews and observations.
- Advance to Section 5: Cognitive Impairment Screen. Ask the designated questions regarding the resident’s cognitive functions, ensuring you document any noted behaviors.
- Once all information is entered, you can save your changes, download the form for printing, or share it as needed.
To ensure a smooth admission process, complete the DOH-4397 online today.
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