Patient Form

FOREST HILL HEALTHCARE CENTER ON-LINE PATIENT REFERENCE FORM

Complete this form to have the patient evaluated immediately by our Admissions Office. Our staff will contact you within hours!

Today's Date:

Hospital Attending Physician:

Hospital:

Room Number:

Patient Information

Patient's Name:

Birth Date:

Age:

Sex:

Primary Language:

Address

Family Contact Name:

Relationship:

Email Address:

Home Phone Number:

Mobile Phone Number:

Reason for Hospitalization:

Hospital Admission Date:

Anticipated Release Date:

Describe any surgeries and/or emergency procedures during this hospital stay:

Describe other ailments, conditions or injuries:

Insurance Information

Medicare:

Medicaid:

Private Insurance:

Secondary Insurance:

Authorization to Access Patient and Patient Record

By the completion and submission of this form, the patient and/or responsible party(ies) provide(s) Forest Hill Healthcare Center permission to access the patient's hospital record, and to discuss and review the patient's care needs with the patient's attending physicians, specialist, hospital social workers/case managers, nurses, and insurance representatives. If required, the patient and/or responsible party(ies) shall agree to an in-person hospital visit with a representative from Forest Hill Healthcare Center. Any and all Personal Health Information (PHI) collected by Forest Hill Healthcare Center during the admission evaluation process shall remain confidential and protected from access by and use by third parties.


The above information is true to the best of my knowledge. I authorize Forest Hill Healthcare Center to contact me, to contact my healthcare professionals rendering care to me including physicians, nurses, social workers, case managers and other healthcare professionals, to contact representatives from my insurance companies, and to access my medical record(s), as part of the admission process to evaluate me as a candidate for admission. I acknowledge that the submission of this form and the gathering of information regarding my care needs and treatments, is not an offer of admission or a guarantee that I shall be admitted to Forest Hill Healthcare Center, and that the submission of this form and the gathering of information, does not provide me with any admission rights whatsoever.

I acknowledge that if I am the patient's responsible party, I am either the spouse, the significant other, a parent, a sibling, or an adult child of the patient, or that I am the patient's Power of Attorney for healthcare decision purposes, or that I am the legally appointed guardian, and that I am aware of the patient's healthcare needs and the patient's desires pertaining to his/her healthcare needs.

Patient/Guardian Name:  

Today's Date:  

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