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- Click ‘Get Form’ to open the dhsr ac 4207 in the editor.
- Begin by filling out the 'Identifying Information' section. Enter the name of the home/facility, followed by the resident's full name, date of admission, and former address. Ensure you check the appropriate box for where the resident was admitted from.
- Continue with personal details such as birthdate, birthplace, and insurance information. Make sure to provide accurate data for Medicare and Medicaid numbers.
- In the 'Personal Information' section, indicate any assistance required by checking relevant boxes. This includes daily activities like dressing or bathing.
- Complete sections regarding community involvement and personal habits. This helps in understanding the resident's background and preferences.
- Finally, ensure that all signatures are obtained in Section F after reviewing all completed sections with the resident or responsible person.
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