Silver Home Care

Client Profile

CONFIDENTIAL - HIPAA PROTECTED

1. CLIENT INFORMATION

Personal Information

Contact Information

Service Address

2. CONTACTS & MEDICAL PROVIDERS

Primary Contact (Main person for day-to-day scheduling and routine care decisions)

Emergency Contact

Medical Providers

4. HOME INFORMATION

Code:

5. PAYMENT & INSURANCE

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Date

Important:

Please have the following ready for our visit:

  • Power of Attorney (POA) document (if applicable)
  • Current medication list
  • Photo ID
  • Insurance cards (Medicare, Medicaid, etc.)
  • Any recent hospital discharge instructions