Client Intake Form – Service Coordination Of MD

Service Coordination of Maryland
Client Intake Form

Date

Contact:

Facility:

Phone:

Address:

Client’s Name:(Required)

DOB:

SSN:

Insurance:

Diagnosis:

Income:

Family/Emergency Contact:

POA/Guardian:

Level of Care:

Email the completed form to:

Please call the office to confirm and follow up the process of the referral.

Notes

The client went to the doctor this week, and it was said by the GI doctor that soon his tube will be removed soon, so he can eat regularly. The paperwork from the GI doctor will be emailed along with the HPF, MOLST, and DS. The client is concerned with being transported to see his sister in West Baltimore. He may need MTA mobility. The client was getting TDAP and FS but he was cut off for reasons unknown. The client should be getting SSI or SSDI.