FORM #6 - INSTRUCTION SHEET

  • Thank you for choosing Temah HealthCare Services, LLC for your care or for the care of your loved one. We look forward to bringing extraordinary care to your home, leaving you with a memorable experience.

    Our service areas includes Anne Arundel, Baltimore City, Baltimore County, Carroll County, Fredrick County, Harford County, Howard County, Montgomery County, and Prince George’s County.

     

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • In order to provide excellent care, we need to obtain as much information as possible prior to the visit. Attached are some forms we need you to fill out and/or sign and fax back or mail to us prior to scheduling your visit.

    1. Patient Information Sheet
    2. Medical History Form and Medication Form (Please fill this out to the best of your knowledge and ensure to complete forms)  
    3. Patient Consent / Acknowledgment 
    4. Emergency Treatment Procedure
    5. Notice of Information Practices and Acknowledgement of Receipt of Notice of  Privacy Policies (Keep the notice of information practices page for your record, complete page 2 and return form)
    6. Authorization for Disclosure to Release Medical Information (Please fill in the following: Patient Name, DOB, Social Security #, Signature, Relationship, Date and Print Name)

     

    Kindly mail all of the above information along with a copy of primary and secondary insurance cards (both front and back) to our office. This will enable us to schedule your appointments as soon as we receive all forms.

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