Is the Patient a Veteran
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IF Yes, Are they Connected with VA Services
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IF YES, was UM Department Notified?
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IF YES, was RN Case Manager at Northport VA Medical Center Notified?
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IF YES, Was the Department of Veterans Affairs notified on 72 Hours Notification Hotline?
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Enter any comments for Section 4 Veterans Services
let us know your comments for this section
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Where does the patient currently live or reside?
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IF patient lives at home who do they live with
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IF they live with someone who do they live with?
Who do they lived with?
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How many steps are there to enter in front of the house?
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How many steps are there to enter Bedroom
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If patient lives in an Apartment who do they lives with
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IF they live live in an APT with someone who do they live with?
Who do they lived with?
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Does the apartment have an elevator?
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If no elevator how many flights of stairs is the walk up
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Select the SAR/NH Facility the Patient is coming from
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If SAR/NH Facility not listed above, please enter name here
Name of SAR/NH Facility not listed above
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Enter Details or Facility Not Listed Above
Enter Details of Facility Not Listed Above
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Enter any comments for Section 5 Demographics
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Does the facesheet have an updated address
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If facesheet didn't have an updated address did you notify registration?
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Does the Facesheet have updated contact information
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If facesheet didn't have updated contact information did you notify registration?
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Enter any comments for Section 6 Facesheet
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Functional Status
Choose the patients functional needs
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Enter any comments for Section 7 Functional Status
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8. DME's PRIOR TO ARRIVAL
Patients DME's Prior to Arrival
Choose the patients functional needs
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If the patient has other DME's describe here
Tell us about other DME\'s
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Enter any comments for Section 8 DME's
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