
DSS-2949 FACILITY NAME ROOM NO. PERSONAL DATA SHEET RESIDENT S NAME Last First M. I. DATE OF BIRTH RELIGION NOTIFY IN CASE OF EMERGENCY NAME STREET STATE RELATIONSHIP PHONE SOCIAL SECURITY NO. ATTENDING PHYSICIAN CITY SEX M F ZIP CODE 3Office Emergency4 OTHER HEALTH/MENTAL HEALTH PROVIDERS Phone POLICY NO. TYPE HEALTH INSURANCE AREA HOSPITAL/CLINIC OF CHOICE ADDRESS Street City Zip Code MARITAL STATUS NAME OF RESIDENT S REPRESENTATIVE F Single FAMILY F Married INFORMATION F Widowed F Divorced F Unknown BURIAL INSTRUCTIONS ADMISSION DATE ADMITTED FROM Own Home SNF HRF DCF Other Specify ADDRESS ADMITTED FROM Street City State Zip Code COUNTY Hospital DMH Facility ADMISSION/ DISCHARGE RESIDENT S ADMISSION SPONSOR if any Own Home ADDRESS DISCHARGED TO Street City State Zip Code REASON FOR DISCHARGE. ATTENDING PHYSICIAN CITY SEX M F ZIP CODE 3Office Emergency4 OTHER HEALTH/MENTAL HEALTH PROVIDERS Phone POLICY NO. TYPE HEALTH INSURANCE AREA HOSPITAL/CLINIC OF CHOICE ADDRESS Street City Zip C....
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How to fill out the DSS-2949 online
Filling out the DSS-2949 is an essential step in documenting personal and health information for residents. This guide provides you with clear, step-by-step instructions to complete the form online effectively.
Follow the steps to complete the DSS-2949 without hassle.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the facility name and room number where applicable, ensuring accurate information as this identifies the location of the resident.
- Fill out the personal data section, including the resident's name (last, first, M.I.), date of birth, and religion. Be attentive to each field to ensure correctness.
- In the ‘Notify in case of emergency’ section, provide the name, address, relationship, and phone number of a designated contact who can be reached in an emergency.
- Enter the social security number, attending physician’s name, and their contact information, including city, state, and phone number.
- List any other health or mental health providers by filling in their names, addresses, and phone numbers in the respective fields.
- Indicate the health insurance information by specifying the policy number and type, ensuring that the details are accurate and up to date.
- Select the area hospital or clinic of choice, providing complete address details.
- Complete the marital status section accurately, identifying whether the resident is single, married, widowed, divorced, or if the status is unknown.
- In the burial instructions section, specify any relevant details as needed.
- Provide information on the admission date and from where the resident was admitted (options include own home, hospital, SNF, HRF, DCF, or other). Include the full address of the place admitted from.
- Fill out the discharge date and where the resident will be discharged to with similar options, ensuring all contact details are provided accurately.
- Conclude by reviewing the entire form for any inaccuracies or missing information and saving the changes, downloading, printing, or sharing the completed document as necessary.
Complete your DSS-2949 and other documents online today for streamlined processing.
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