DOH-4397 2006 free printable template
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The ALR Resident Personal Data Form DOH 4397 Part A and the Resident Evaluation Form DOH 4397 Part B meet the requirements for the Adult Care Facility ACF Personal Data Sheet the ACF Pre-Admission Interview and the Enriched Housing Program EHP Functional Assessment. ASSISTED LIVING RESIDENCE ALR RESIDENT PERSONAL DATA and ALR RESIDENT EVALUATION INSTRUCTIONS General Directions The ALR Resident Personal Data Form DOH 4397 Part A and ALR Resident Evaluation Form DOH 4397 Part B must be...
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How to fill out DOH-4397
How to fill out DOH-4397
01
Obtain the DOH-4397 form from the appropriate health department website or office.
02
Fill in the patient’s personal information including full name, date of birth, and address.
03
Indicate the purpose of the form by checking the appropriate box.
04
Provide information regarding the patient's medical history as required.
05
Complete the sections regarding any relevant health insurance details.
06
Sign and date the form to certify that the information provided is accurate.
07
Submit the completed form to the designated health department office or as instructed.
Who needs DOH-4397?
01
Individuals seeking certain health services or records managed by the health department.
02
Patients who need to authorize the release of their health information.
03
Caregivers or legal representatives filling out on behalf of the patient.
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What is DOH-4397?
DOH-4397 is a form used by certain healthcare facilities to report specific information to the Department of Health regarding patient care and administrative practices.
Who is required to file DOH-4397?
Healthcare facilities, including hospitals and nursing homes, that provide specific types of patient care are required to file DOH-4397.
How to fill out DOH-4397?
To fill out DOH-4397, facilities must gather relevant patient data and administrative information, accurately complete each section of the form, and submit it to the designated department in a timely manner.
What is the purpose of DOH-4397?
The purpose of DOH-4397 is to collect data that helps the Department of Health monitor healthcare quality and compliance, and to support public health initiatives.
What information must be reported on DOH-4397?
DOH-4397 requires reporting information such as patient demographics, treatment types, services provided, and any relevant outcomes or incidents related to patient care.
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