Get Admission Record

This guide provides comprehensive instructions for completing the Admission Record online. Whether you are a user familiar with digital document management or new to the process, this step-by-step guide will help ensure that all required information is correctly filled out.

Follow the steps to successfully complete the Admission Record.

1. Click the ‘Get Form’ button to access the Admission Record. This action will allow you to open the document for online editing.
2. Begin by entering the patient information, including the resident's full name and date of birth. Make sure to fill in the correct format for the date (MM/DD/YYYY). Proceed to indicate the resident's gender by checking the appropriate box.
3. Next, input the social security number and the service start date. Ensure that these fields are filled out accurately as they are essential for identification.
4. Complete the facility information section by providing the facility name, contact person, address, city, state, zip code, phone, and fax numbers. Double-check that all contact details are correct to avoid any communication issues.
5. Choose the packaging preference for medications by checking either 'Bubble Packs' or 'Vials'. Note that all medications will be packaged in non-child resistant bubble packs unless specified otherwise.
6. Document any known allergies and provide the current diagnosis. This information is important for medical professionals to ensure safe medication dispensing.
7. Fill out the physician information, including the primary physician's name, phone, and fax details. If applicable, include a secondary physician's information as well.
8. In the contact/billing information section, provide the name of the financially responsible party, their relationship to the patient, and complete the address fields accurately. Include phone and cell phone numbers for possible follow-up.
9. Enter the insurance details, including insurance company name, policy number, group number, bin number, and PCN number. This information is typically found on the insurance card. If the patient is covered by Oregon Medicaid, please provide the I.D. number.
10. Read and understand the statements regarding financial responsibility and HIPAA compliance. By signing the document, you acknowledge your understanding and consent to the outlined terms.
11. Finally, include the signature of the resident or financially responsible party along with the date of signing. Once all fields are completed, you can save the changes, download a copy of the form, print it, or share it as needed.

Complete your Admission Record online easily and efficiently today.