Get Ny Doh-4397 Part A 2012-2026

Filling out the NY DOH-4397 Part A form online is a crucial step for residents of assisted living facilities in New York State. This guide will provide you with clear instructions on completing this form accurately and efficiently.

Follow the steps to complete the NY DOH-4397 Part A form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In the Resident's Name field, enter the full legal name of the resident. Ensure this matches with identification documents.
3. In the Facility Name section, specify the name of the assisted living residence where the resident will be staying.
4. Fill out the Admission / Discharge Information by providing the date of admission, the county, and the location from where the resident was admitted. Select the appropriate option regarding their previous residence.
5. Indicate the discharge date and the location the resident will be discharged to, similarly specifying options as above.
6. Complete the Personal Data section including Date of Birth, and select Gender accordingly.
7. Provide emergency contact information, including the name and relationship to the resident, along with multiple phone numbers and addresses.
8. List any other health care providers by entering their names, specialties, and contact information.
9. Identify the attending physician with their name, specialty, and contact details.
10. In the Health Insurance section, record all relevant insurance information, including the insurer, Medicaid number, Medicare number, and prescription drug plan information.
11. Proceed to fill out the Personal Background section, including how the resident wishes to be addressed, their representative details, and personal history.
12. Complete sections regarding any advance directives, including DNR status, Power of Attorney, and Health Care Proxy.
13. Once all sections are completed, review the information for accuracy, then save changes, download, print, or share the form as necessary.

Complete your NY DOH-4397 Part A form online today for a smooth admission process.