Registration | The Holding Group

Who is filling out this form?**

Reason for referring this person?**

Healthcare Facility or Agency Name

Primary Care Provider

Specialty Care Provider

Other important care team members

Patient First Name **

Patient Last Name **

Patient Date of Birth **

What is Patient living situation?

Gender Identity

Is the patient Hispanic/Latin/a/o/x?

Patient Language

English

Spanish

Other

Race(s) check all that apply

American Indian / Alaskan Native

Asian

Black / African American

Native Hawaiian / Pacific Islander

White / Caucasian

Other

Decline to Provide

Patient Language

Race(s)

Patient’s Email**

Is the Patient the Primary Contact?*

If the patient is not the primary contact, what is the Primary Contact’s Full Name*

Primary Contact’s Phone Number**

Primary Contact’s Email Address:**

Relationship to Patient

Medicare ID Number

Does the patient have a dementia diagnosis?

What secondary insurance

How did you hear about us?

Does the patient have Medicare?

Yes

Is patient’s Medicare managed by an insurance company such as United, BCBS or Kaiser?

Yes

Does the patient have a secondary/supplemental insurance?

Yes

Does the patient of Medical Orders for Scope of Treatment (MOST) in place?

Yes

Not Sure

Medical Durable Power of Attorney?

Yes

Not Sure

List all current medications including dosages and frequencies

Please Check All that Apply

Eye Glasses

Hearing Aid

Oxygen

Wheelchair

Walker

Cane

None of the Above

Diet

Regular

Diabetic

Low Salt

Please upload relevant medical information (H&P Med List and Visit Notes)

Max. file size: 512 MB.

Your health information is kept private under federal HIPAA regulations. If you wish to share your medical information with a third party, please fill out the form below. Examples would be for disability, information needed for work release, or if you need a letter, or want us to talk with family members that are not designated as part of your care team.  

HIPAA permits health care providers to disclose to other health providers any protected health information (PHI) contained in the medical record about an individual for treatment, case management, and coordination of care and, with few exceptions, mental health information is treated the same as other health information.

Acceptane*

I have reviewed and agree to the holding group Privacy Statement (click to review)

Comments

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