Please provide us the requested information. All required fields are denoted with an asterisk (). You may save your progress at any time.
1. Patient Rights handout provided?
2. Do you or significant others / care givers(s)have special need or disability?
3. May we share your name, general condition, religious affilaltion and room number with those who ask(i.e friends who call, clergy, etc.)?
4. In the event of a medically necessary circumstance, will you accept a blood transfusion or blood products?
5. Do you have a patient representative/support person?
b. If inpatient, may we notify your personal representative/friend/family that you have been admitted?
If UNABLE TO DETERMINE(follow policy and document actions taken in Paragon.Notification of admission Completed.
6. For EMERGENCY ROOM visits, may we notify your Family Physician that you have been seen in the Emergency Room?
May we notify your family physician that you have been admitted?
7. Visitation Rights given
8. Advance Directive Brochure and From Provided. Document status in Paragon.
9.Immunization - We report immunizations to the state and Federal goverment (If you would like to optout of the reporting please circle)
10. Are you participating in a Clinical Research Study?
11. If first encounter or when updated, provide Notice of Privacy Practices (Entered in Paragon)
12. If Medicare inpatient, Message of Medicare Rights notice given:
13. Privacy Password Provided (last 4 digits of account number):