Form Dhsr/ac 4207 - Resident Register printable pdf download

DHSR/AC 4207 (Rev. 09/11) NCDHHS

RESIDENT REGISTER

The following resident information is to be completed and signed by the Administrator or Supervisor-in-Charge/Administrator-in-

Charge and the resident or his/her responsible person within 72 hours of admission and kept in the resident’s record in the home.

Write “N/A” if the requested information is not applicable to the resident.

NAME OF HOME/FACILITY ________________________________________________________________________________

A. IDENTIFYING INFORMATION

1. NAME______________________________________________________________________________________________

(first)

(middle)

(last)

(what resident prefers to be called)

2. DATE OF ADMISSION________________________________________

(month)

(day)

(year)

3. FORMER ADDRESS _________________________________________________COUNTY:________________________

 Own Residence

 Another’s Residence

ADMITTED FROM:

A facility:_______________________________________________________________________

(Name)

(Address)

Other:__________________________________________________________________________

4. BIRTHDATE__________________ BIRTHPLACE______________________ SS#_______________________________

5. MEDICARE #_________________MEDICAID #__________________OTHER INSURANCE #’S____________________

6. MARITAL STATUS  Single

 Married

 Partnered

 Widowed

 Divorced

 Separated

7. GENDER  Female

 Male

 Caucasian

 African-American

 Native-American

 Hispanic

 Other________________

8. RACE

9. FAMILY

Father____________________________________ Mother________________________________________

(include maiden name)

CHILDREN__________________________________________________________________________________________

SIBLINGS___________________________________________________________________________________________

SPOUSE/PARTNER (Address if applicable)________________________________________________________________

10. RESPONSIBLE PERSON (if applicable)___________________________________________________________________

Phone (

)

Address______________________________________________________________________________________________

Nature of Responsibility:  Guardian

 Power of Attorney

 Payee

11. CONTACT PERSON (If responsible person is not designated)__________________________________________________

Phone (

)

Address:_____________________________________________________________________________________________

12. PERSON IDENTIFIED BY THE RESIDENT TO RECEIVE A COPY OF THE DISCHARGE NOTICE

Name _____________________________________________ __________________________________________________

Phone (

)

Address______________________________________________________________________________________________

B. RESOURCE INFORMATION

1. ATTENDING PHYSICIAN:_____________________________________________________________________________

Address______________________________________________________________________________________________

Form Dhsr/ac 4207 - Resident Register

Related Articles

Related forms

Related Categories