Date Portable Health Profile PHP Data Collection Form This form contains information that is confidential. It may contain information that is privileged or exempt from disclosure under applicable law. 1. Personal Information Name Date of Birth Street City Home Phone State Mobile Phone 2. Emergency Contacts Relationship Address Phone 1 3. Health Insurance Information Insured Name ID Number Group Name Subscriber Name Primary Insurance Plan Name Phone Number Group Number Secondary Insurance Plan Name Claim Manager Claim Number Type text Workers Compensation Agency Name Sex Advance Directive Yes No Primary Language 4. Immunizations Flu Vaccine Pneumonia Vaccine Tetanus 5. Risk Factors Legally Blind Hip Precautions Swelling Problems Date Administered Chicken Pox Vaccine HPV Sternal Precautions Prone to fall Bleeding Precaution 6. Physicians Other Healthcare Providers involved in my care Senior Network Health VNA Meals on Wheels Oxygen Provider Home Health Care Primary Physician Dentist Spec....
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How to fill out the UMMS Portable Health Profile (PHP) Data Collection Form online
The UMMS Portable Health Profile (PHP) Data Collection Form is essential for gathering important health information. This guide provides clear, step-by-step instructions to help you complete the form online efficiently and accurately.
Follow the steps to fill out your Portable Health Profile form with ease:
- Select the ‘Get Form’ button to access the Portable Health Profile Data Collection Form and open it in your preferred format.
- Begin with the Personal Information section. Fill in your full name, date of birth, street address, city, state, home phone number, and mobile phone number.
- Proceed to the Emergency Contacts section. Provide details for at least two emergency contacts, including their names, relationship to you, addresses, and multiple phone numbers.
- In the Health Insurance Information section, input your insured name, ID number, group name, subscriber name, and subscriber ID number for both primary and secondary insurance plans.
- Complete the Immunizations section by listing the immunizations you have received. Be sure to include the vaccine name and the date administered.
- In the Risk Factors section, indicate any health-related risk factors that apply to you by checking the relevant boxes.
- List your Physicians & Other Healthcare Providers involved in your care in the corresponding section. Include names and any relevant organizations.
- Provide your Preferred Hospital's name and phone number in the next section.
- Document any Allergies you have by listing them in the designated area.
- Record any Medications, Vitamins, or Supplements you are taking, including their names, dosages, and frequency.
- Detail any Medical Devices you use, including the type, provider, provider number, and the date you obtained or last had them serviced.
- Note Known Medical Conditions or Diagnoses by checking the applicable boxes or adding others if necessary.
- Identify any Special Needs you have regarding functional mobility, vision/hearing, and swallowing.
- Once all sections are complete, save your changes, and if needed, download, print, or share the form as required.
Start filling out your Portable Health Profile form online today!
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