Fillable Patient Hospital Provider

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Patient Hospital Provider

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The Patient Hospital Provider form is 1 page long and contains:

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  • 33 check-boxes
  • 66 other fields

Country of origin: OTHERS
File type: PDF

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Hospital Admission/Discharge Form
Fax completed form to (952) 853-8705
Sender/Caller Information:
□
Patient
□
Hospital
□
Provider
Name: _____________________________ Phone: (______)______________ Fax: (______)______________
Does the patient have other insurance? □ No □ Yes: ______________________________________
Today’s Date: _____/_____/_______ Time: _____:_____ _____
Patient Information:
Patient: _______________________________ _______________________________
Last First
HealthPartners Member ID # : __________________ Date of Birth: ____/____/______ □ Male □ Female
Provider Information:
Facility: ______________________________________________ Phone: (______)___________________
Street: _____________________________________________ UR Dept: (______)___________________
City: _____________________________________ State: ___________ Zip: ___________________
Facility Tax ID: ________________________________ Provider Contact Name: _________________
Attending Physician: _______________________________ _______________________________
Last First
Phone: (______)___________________ Fax: (______)_____________________
Street: _______________________________________________________________________________
City: _____________________________________ State: ___________ Zip: ___________________
Physician Federal Tax ID: ________________________ or NPI #: ______________________________
Please include admission H&P information along with this form.
Updated 1/9/20
Admission Information:
Admission Date: _____/_____/_______
Discharge Date: _____/_____/_______
Disposition: □ Home □ Expired □ Nursing Home Transfer □ Other Hospital Transfer
Admission Source:
□ ER/ED
□ Direct
□ Scheduled
□ Direct Transferred From: _____________________________
Admission Type, Bed, Unit (mark all that applies): □ Other ________________________________________
□ Med/Surg
□ ICU/CCU
□ Long Term Acute Care
□ Pediatric
□ Swing Bed
□ Inpatient Acute Rehab
□ Maternity Delivery/DOB: _____/_____/_____
Nursery: □ Normal □ Level II □ Level III NICU
□ Twins □ Triplets
Baby: □Boy □Girl Name: Last________________ First______________ Hospital MRN: ___________
Baby: □Boy □Girl Name: Last________________ First______________ Hospital MRN: ___________
Baby: □Boy □Girl Name: Last________________ First______________ Hospital MRN: ___________
IC
D-10 Diagnosis Code: ___________________________________________________________________
ICD-10 Procedure Code (Inpatient): __________________________________________________________
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Patient Hospital Provider

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Completed 7 January 2021

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