Admission form 2025

1. Click ‘Get Form’ to open the admission form in the editor.
2. Begin by filling out the Identifying Information section. Enter your Medicaid number, date, last name, first name, middle initial, date of birth, age, sex, and date of admission. Ensure all fields are completed accurately.
3. In the Current Living Arrangements section, select the appropriate option that describes your living situation. If applicable, provide details about the commitment type and effective date.
4. Describe the primary symptom requiring acute hospital care in Section IIA. Include any precipitating events leading to admission for a comprehensive overview.
5. Complete Section IIB with relevant clinical information and attach additional pages if necessary. Document any psychiatric medications in Section IIC.
6. Fill out past drug/alcohol usage in Section IID and previous psychiatric treatment details in Section IIE.
7. Provide admitting diagnosis and additional diagnoses in Sections III and IV respectively. Complete functional assessment scores in Section V.
8. Indicate the number of hospital days requested and projected discharge date in Section VI.
9. Finally, complete the Aftercare Plan section with provider details and ensure you sign and print your name at the end of the form.

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