Get the free International Patient Information Form - UC Davis Health

Email to iVisitors ucdmc.ucdavis. edu Fax to 01-1-916-734-7055 Mail to International Patient Services 4610 X St. Suite 3101 Sacramento CA 95817 USA INTERNATIONAL PATIENT INFORMATION FORM Contact Information Patient name First Middle Last Phone Fax Cell E-Mail Home address Name of U.S. Pointof-Contact if any Name Address Emergency Contact spouse sibling adult child etc. If patient is a child parent must be listed Referring Physician in Home Country if any International Patient Information Form...

How to fill out international patient information form

How to fill out international patient information form

1. Read all instructions provided on the international patient information form.
2. Start by filling out your personal details, such as your full name, date of birth, and contact information.
3. Provide information about your medical history, including any existing conditions, past surgeries, and medications you are currently taking.
4. Indicate the purpose of your visit, whether it is for medical treatment, consultations, or other specific reasons.
5. If you have any allergies or sensitivities, make sure to mention them in the appropriate section of the form.
6. Include the name and contact information of your primary healthcare provider or referring physician, if applicable.
7. If you have insurance coverage that may be applicable to your treatment, provide the necessary details.
8. Complete the form by signing and dating it.
9. Review the form to ensure all information is accurate and complete before submitting it.

Who needs international patient information form?

1. Anyone who is a non-resident seeking medical treatment in a foreign country.
2. Individuals who are traveling abroad to receive specialized medical care or consultations.
3. Patients who wish to access healthcare services in a different country due to availability, cost, or expertise.
4. International students studying abroad who require medical attention during their stay.
5. Foreign nationals visiting another country for medical tourism purposes.

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What is international patient information form?

The international patient information form is a document used to collect important details about patients from other countries who seek medical treatment abroad.

Who is required to file international patient information form?

Healthcare providers and hospitals are required to file the international patient information form for any patients from overseas they treat.

How to fill out international patient information form?

To fill out the international patient information form, healthcare providers need to gather details such as patient's name, country of origin, medical history, treatment received, etc.

What is the purpose of international patient information form?

The purpose of the international patient information form is to keep track of patients from other countries receiving medical treatment, ensure proper care, and monitor international patient statistics.

What information must be reported on international patient information form?

Information such as patient's name, age, gender, country of origin, medical history, treatment received, length of stay, etc. must be reported on the international patient information form.