User Guide: Hospice Care Admission Form
This user guide will help you understand how to properly complete the Hospice Care Admission Form. The form is designed to collect essential information about patients entering hospice care.
Overview
The Hospice Care Admission Form is a comprehensive document that gathers:
- Patient personal information
- Medical history and current health status
- Emergency contact details
- Insurance information
- Advance directive preferences
- Spiritual and cultural considerations
- Consent for hospice care services
How to Complete the Form
Section 1: Patient Information
- Full Name: Enter the patient's legal first, middle, and last name
- Date of Birth: Use the calendar picker or enter in MM/DD/YYYY format
- Address: Include street address, city, state, and ZIP code
- Phone Number: Provide the best contact number for the patient
- Gender: Select the appropriate option from the dropdown
- Marital Status: Select the appropriate option from the dropdown
Section 2: Medical Information
- Primary Diagnosis: Enter the main medical condition requiring hospice care
- Date of Diagnosis: When the primary condition was first diagnosed
- Secondary Diagnosis: Any additional significant health conditions
- Attending Physician: Name of the doctor primarily responsible for care
- Current Medications: List all medications, dosages, and frequency
- Allergies: Note any drug, food, or environmental allergies
Section 3: Emergency Contact Information
- Contact Name: Full name of the primary emergency contact
- Relationship: How this person is related to the patient
- Phone Numbers: Provide primary and alternate contact numbers
- Email Address: For electronic communication
- Address: Where the contact person resides
Section 4: Insurance Information
- Insurance Provider: Company name providing coverage
- Policy Number: Patient's identification number with the insurer
- Group Number: If applicable to the insurance plan
- Medicare/Medicaid Numbers: If the patient is enrolled in these programs
Section 5: Advance Directives
- Living Will: Indicate whether the patient has a living will
- Power of Attorney: Note if there's a healthcare power of attorney
- Location: Where these documents are kept for reference
Section 6: Spiritual and Cultural Preferences
- Religious Preference: Patient's religious affiliation, if any
- Clergy/Spiritual Advisor: Contact information for spiritual support
- Cultural Considerations: Any important cultural practices or preferences
Section 7: Consent for Hospice Care
- Read the consent statement carefully
- Provide required signatures with dates:
- Patient signature (if able)
- Representative signature (if applicable)
- Witness signature
Technical Instructions
Digital Form Usage
- Tab between fields for efficient navigation
- Use the calendar icon (📅) to select dates
- All fields with asterisks (*) are required
- Click the "Print Form" button when ready to create a physical copy
Printing the Form
- Use the "Print Form" button at the bottom of the page
- Ensure your printer has adequate paper and ink
- For best results, use portrait orientation and standard letter size (8.5" × 11") paper
- Review the printed form for completeness before signing
Tips for Completion
- Have insurance cards and medication lists available before starting
- Consult with family members or caregivers for accurate information
- Complete all sections to the best of your ability
- Ask hospice staff for clarification if any questions arise
- Keep a copy of the completed form for your records
Privacy and Security
- This form contains sensitive personal health information
- Store completed forms in a secure location
- Share only with authorized healthcare providers
- Properly dispose of any drafts or unwanted copies
If you need assistance completing this form, please contact our hospice admissions team at [Phone Number] or [Email Address].