Hospital And Ambulatory Surgical Center Fax Report Form Page 6
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HOSPITAL AND AMBULATORY SURGICAL CENTER FAX REPORT FORM
TO:
INTAKE STAFF
DEPARTMENT OF PUBLIC HEALTH, DIVISION OF HEALTH CARE FACILITY LICENSURE AND
CERTIFICATION
FAX NUMBER: 617-753-8165
FROM:
Facility Name:
_____________________________________________________________
Address (Street):
_____________________________________________________________
Address (City/Town):
_____________________________________________________________
Report prepared by (Name/title): _______________________________________________________
Telephone #:
______________________________________________________________
DATE OF REPORT:
_______________
NUMBER OF PAGES: ____________
DATE OF OCCURRENCE:
Month: ____________ Day: _________ Year: ________
TIME OF OCCURRENCE:
________________________ am______ pm_______
IF ABUSE, NEGLECT, or MISAPPROPRIATION IN A NURSING HOME, REST HOME, HOME HEALTH,
HOMEMAKER, OR HOSPICE AGENCY AND NOT THE REPORTING HOSPITAL:
Facility/Agency Name: _____________________________________________________________
Address:
_____________________________________________________________
PATIENT INFORMATION:
Name:
First: _________________________
Last: ___________________________
Age:
______________
Date of Birth:
Sex:
Male _________
Female __________
Admission Date:
Month: ___________ Day: __________ Year: ________
Ambulatory Status (See table #1): ________________________________________
ADL Status (See table #2):
___________________________________________
Cognitive Level (See table #3):
___________________________________________
Developmentally Disabled:
____ Yes ____No.
If yes, Service Coordinator or Case Manager (if known): _________________________________
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