Get Legacy Community Health Client Intake 2021-2025

Completing the Legacy Community Health Client Intake form is an essential step in establishing your care. This guide provides clear instructions to help you navigate the online form with ease and confidence.

Follow the steps to accurately fill out the Client Intake form.

1. Click ‘Get Form’ button to obtain the Client Intake form and open it for completion.
2. Enter the patient's first, middle, and last name as well as their preferred name, if applicable. Provide the mother's maiden name for identification purposes.
3. Fill in the patient's date of birth and today's date. Enter the name of the parent or legal guardian if the patient is under 18 years of age. Indicate the patient's age.
4. Provide identification information including the driver's license number or another form of ID, as well as the address, city, state, and ZIP code.
5. Indicate if there is an alternate address for preferred mailing. If so, include the address, city, and ZIP code.
6. List the county of residence, state or country of birth, and provide the main phone number and social security number. Add any additional phone numbers if applicable.
7. Answer whether the patient is homeless. Indicate the preferred method of contact from the options provided.
8. Indicate the patient's marital status, sex at birth, family size, occupation, and total family household income. Specify if the income is annual or monthly.
9. Choose the patient's ethnicity and race. You may select multiple options when applicable.
10. For patients 18 years old and above, provide details regarding sexual orientation and current gender identity, if comfortable.
11. Fill in emergency contact details including the name, relationship to the patient, and their phone number.
12. State the patient's preferred pharmacy if applicable, providing the name, address, and phone number.
13. Complete insurance information if applicable, including Medicaid, Medicare, or private insurance details.
14. Review the consent statements regarding financial responsibility and treatment. Sign where indicated to confirm understanding and consent.
15. Finally, save changes to your form. You may download, print, or share it as needed.

Start filling out your Legacy Community Health Client Intake form online today for a smoother healthcare experience.