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Phone: (956) 353-6055
Fax: (956) 353-6011
ADMINISTRATOR JOR FLORES, RN/DOPS
Cell: (956) 929-1204
j.flores@physicianpreferred-hhs.com

Intake Referral Form

    Individual Name: Primary Language:
    Gender: Marital Status:
    Phone: Alternate Phone: D.O.B.:
    Social Security: Medicaid: Medicare:
    Physical Address: City:
    Lives: Name and Relationship:
    Emergency Contact: Relationship:
    Address: Phone:
    List Tasks:
    Diagnosis:
    Assistive device? List:
    Hospital admissions last three months?
    Hospital Name: City / State:
    Reason for hospitalization
    Date of Admission: Date of Discharge:
    Primary Phtysician Name: Phone:
    Address: City:

    Dialysis Center? Facility: Days/Hrs: Phone
    DAHS? Facility: Days/Hrs: Phone
    Attendant of Choice: Phone
    Referred by whom: Phone
    Comments:
    Verified individual status: Intake#:  
    DADS Intake Coordinator: Date:
        
    Signature of person completing form Date