Get the free SHS Patient Information Form - Moscow Family Medicine

Patient Information Form C O N T Y A O C U T I N G I N S U R A N C E Patient Name: Last First MI Patient is a: UI Student Students Spouse Students Child Students Name if different from patient: Student

How to fill out shs patient information form

How to fill out SHS patient information form:

1. Start by writing your personal information at the top of the form. This typically includes your full name, address, contact number, date of birth, and gender.
2. Next, provide details about your insurance coverage. If you have insurance, fill in the policy number and the name of the insurance provider.
3. Indicate your emergency contact information. This should include the name, phone number, and relationship of the person who should be contacted in case of an emergency.
4. Fill out your medical history. Include any chronic conditions, allergies, or previous surgeries that may be important for your healthcare provider to know.
5. Provide a comprehensive list of any medications you are currently taking, along with the dosage and frequency. This is crucial for ensuring safe and accurate treatment.
6. If applicable, fill in any past hospitalizations or major illnesses that you have experienced.
7. Answer questions about your lifestyle, such as smoking or drinking habits, as this information may be relevant to your healthcare.
8. Lastly, sign and date the form to certify its accuracy and completeness.

Who needs SHS patient information form:

1. Any individual seeking medical treatment at an SHS (Student Health Services) facility would be required to fill out the patient information form.
2. This form is necessary for both new patients who are visiting the facility for the first time and returning patients who may have updated information to provide.
3. The patient information form ensures that healthcare providers have accurate and up-to-date information about the patient, enabling them to provide appropriate care and treatment.

For pdfFiller’s FAQs

What is shs patient information form?

The shs patient information form is a document used to collect and record important medical information about a patient.

Who is required to file shs patient information form?

Healthcare providers and facilities are required to file the shs patient information form for each patient they see.

How to fill out shs patient information form?

The shs patient information form can be filled out by entering the patient's personal and medical information in the designated fields.

What is the purpose of shs patient information form?

The purpose of the shs patient information form is to ensure that healthcare providers have all necessary information to provide appropriate care to patients.

What information must be reported on shs patient information form?

The shs patient information form must include the patient's name, date of birth, medical history, current medications, allergies, and emergency contacts.

How can I send shs patient information form to be eSigned by others?

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How do I make changes in shs patient information form?

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