Client/patient Intake Form printable pdf download

Client/patient Intake Form

DATE: ____________________

LOCATION: ____________________

COUNSELOR: ____________________

CLIENT/PATIENT INTAKE FORM

First Name___________________________ Last Name_______________________________________

Address_______________________________________________________________________________

City_________________________ State________ Zip___________ County _______________________

Phone_____________________________________

Date of Birth_____________________________SS#__________________________________________

Medicare Claim # ______________________________________ Effective date: Part A ____________

Part B ___________

Marital Status__________________________ Language spoken ________________________________

The client currently has (please circle all that apply):

Part D

ICRx

LIS

Dual

Unaware Dual

MSP

Medicare Part D plan, Health Insurance, Retiree Coverage, Employer or Group Coverage, Medicaid Spend-

down, HBWD: ___________________________________________________________________

____________________________________________________________ Effective date: _____________

Part D Plan Member ID #/ Company______________________________________________________

How are you paying for your prescription drugs now? _______________________________________

Income ______________________________ Assets ___________________________________________

Would you be willing to talk to someone from the press about your story?

______________________________________________________________________________________

(Note to counselor: If yes, please complete a Media Release Form.)

 Follow Up / Comments

Case Closed

Entered

Client/patient Intake Form