Patient Intake Form

This form is shared by Serene Home Health Care staff after an initial screening call. Please complete all sections as thoroughly as possible.

Patient Information

Patient Full Name*

Age Range*

Gender

Home Address*

City*

State

ZIP Code

Patient Phone*

Patient Email

Preferred Language

Emergency Contact

Name*

Relationship

Phone*

Referral Information

Referral Source

Referring Physician

Physician Phone

Physician Fax

Physician Email

Hospital / Facility

Discharge Date

Care Needs

Primary Diagnosis*

Reason for Referral

Services Requested

Functional Limitations

Mobility Status

Fall Risk

Equipment Needed

Medication Assistance Needed

Home Environment Notes

Caregiver Availability

Safety Concerns

Insurance Information

Primary Insurance

Primary Policy Number

Secondary Insurance

Secondary Policy Number

Medicare Number

Medicaid Number

Managed Care Plan

Veterans Benefits

Private Pay

Care Coordination

Case Manager Name

Case Manager Phone

Case Manager Email

Social Worker Name

Social Worker Phone

Social Worker Email

Clinical Information

Current Primary Physician

Specialists

Recent Hospitalizations

Current Medications

Known Allergies

Existing Providers / Services

Privacy Statement

By submitting this form, you voluntarily provide information to Serene Home Health Care for the purpose of evaluating and coordinating potential services. Information submitted through this form will be handled in accordance with applicable privacy laws and our Notice of Privacy Practices. Please do not submit highly sensitive personal information such as Social Security Numbers through this form.

I acknowledge and agree to the privacy statement above.*