Admission Worksheet for Patient - My Doctor Online

ADMISSION WORKSHEET FOR PATIENT - Page 1 of 3
Dear Patient: To ensure accurate and complete admission information, please complete this form in
its entirety and return it to the Admitting Department. As a Kaiser Permanente patient, you may have
a hospital fee, deductible, copayment, or coinsurance which you are required to pay at the time of
admission. If you would prefer to make a payment in advance of your admission, please call or visit
the Admitting Department.
Thank you.
Admission Date:
Medical Record Number (MRN):
Last Name:
Male
First Name:
Female
PATIENT DEMOGRAPHICS
Address:
SSN: Please Provide Upon Admission
Date of Birth:
City:
Alias(es):
State:
ZIP:
Home/Mobile Phone:
Ethnicity
Race:
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
Religion:
Marital Status:
Common Law
Divorced
Legally Separated
Employer
Address:
Occupation:
Country:
Email Address:
Work Phone:
During your admission, we
have your permission to
disclose
(check all applicable boxes):
EMPLOYER
Other
MI:
White
Other
Unknown
Declined to State
Spiritual Need Visit Requested?
Married
Registered Domestic Partner
Separated
Yes
No
Single/Never Married
Widowed
Other
Name
Condition
Location/Phone
Religion
No Information - Confidential Admission
Employment Status:
Full-time
Not Employed
On Active Military Duty
Part-time
City:
Retired
Self-employed
Student full-time
Student part-time
State:
Phone:
ZIP:
Country:
LABOR & DELIVERY PATIENTS ONLY
ADDITIONAL
INFO
DOCUMENTS
EMERGENCY CONTACTS
ADMISSION WORKSHEET FOR PATIENT - Page 2 of 3
Last Name:
Address:
Work Phone:
Last Name:
Address:
Work Phone:
First Name:
Relationship:
City:
State:
Home/Mobile Phone:
First Name:
ZIP:
Country:
Legal Guardian?
Yes
No
Relationship:
City:
State:
ZIP:
Country:
Legal Guardian?
Home/Mobile Phone:
Yes
Do you have an Advance Health Care Directive?
Yes
No
Do you have a Do Not Resuscitate form?
Yes
No
Do you have a Physician Order for Life Sustaining Treatment form?
Yes
No
No
If yes, please provide copy(ies) to the Admitting Department prior to or upon admission.
Do you need an Interpreter?
Yes
No
Country of Birth:
Preferred Spoken Language:
Preferred Written Language:
Expected Delivery Date:
Patient’s Maiden Name:
NEWBORN INFORMATION
Ethnicity
During your admission, we
have your permission to
disclose
(check all applicable boxes):
Race:
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
Name
Condition
Location/Phone
Religion
No Information - Confidential Admission
White
Other
Unknown
Declined to State
ADMISSION WORKSHEET FOR PATIENT - Page 3 of 3
GUARANTOR
Guarantor Name:
Relationship:
Address:
City:
SSN: Please Provide Upon Admission
Date of Birth:
Employer
Male
State:
City:
SUBSCRIBER
ZIP:
Country:
Phone:
Subscriber Name:
Relationship:
Address:
City:
SSN: Please Provide Upon Admission
Date of Birth:
Male
State:
City:
Medicare HIC #
Please Provide Upon Admission
ZIP:
Country:
Phone:
Other KP Region Coverage:
Please Provide Upon Admission
Country:
Retired
Self-employed
Student full-time
Student part-time
State:
Occupation:
Medicare HIC #
ZIP:
Female
Home Phone:
Employment Status:
Full-time
Not Employed
On Active Military Duty
Part-time
Address:
COVERAGE
Retired
Self-employed
Student full-time
Student part-time
State:
Occupation:
Employer
Country:
Home Phone:
Employment Status:
Full-time
Not Employed
On Active Military Duty
Part-time
Address:
ZIP:
Female
Other KP Region MR Number:
Part A
Effective Date for Part A:
Part B
Effective Date for Part B:
Issue Date:
Workers’ Compensation Claim #:
Date of Injury/Illness:
Workers’ Compensation Policy #:
Other Commercial Insurance:
Group Number:
Insurance ID Number:
Insurance Address:
Insurance Phone:
Effective Date of Insurance Coverage: