Applicants Physician Form

Note: This online form covers diagnoses, medications, exam findings, vital parameters, diet orders, and risk factors only. The Request for ADHC/CBAS Services and Standing Orders sections require your signature and cannot be completed online — our staff will follow up with your office to finalize those by fax or mail.

Patient & Submitting Office

Patient Name *

Sex

Date of Birth

Last Exam Date

EHR EHR attached

Your Name *

Practice / Office Name

Phone *

Email *

Section B — Current Medications

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Medication

Dosage

Route

Frequency

Section C — Physical Examination

HEENT — Comments

Respiratory — Comments

Cardiovascular — Comments

AICD Pacemaker

Breast / Chest — Comments

Gastrointestinal — Comments Bowel incontinence

Genitourinary — Comments Bladder incontinence

Musculoskeletal — Comments

Integumentary — Comments

Neurological — Comments

Significant Physical Limitations

TB Screening & Vitals

Date Vitals Taken

Last PPD Test Date

PPD Result

Positive Negative

Last Chest X-Ray Date

QuantiFERON TB Test Date

QuantiFERON Result

Positive Negative

Weight

Height

Temperature

Blood Pressure

Heart Rate / Pulse

Known Allergies (medication & environmental)

Section D — Vital Parameters

Systolic BP Range

Alternative Range

Diastolic BP Range

Alternative Range

Pulse Range

Alternative Range

Random Glucose Range

Alternative Range

Glucose Testing at Center

If Other, specify

Section G — Request for ADHC/CBAS Services

All participants receive skilled nursing, social services and/or personal care, therapeutic activities, and meal services daily. Additional services (PT, OT, speech, mental health, transportation) are added based on team assessment.

1) Contraindications for receiving additional services? None

2) Medical contraindications for one-way transportation exceeding 60 minutes? None

3) Overall health prognosis?

4) Overall therapeutic/treatment goals?

What happens next: After you submit, we'll send a secure e-signature request to your email through Dropbox Sign containing the Authorization statement and Standing Orders for your review and signature. Your submission here is not considered authorized until that signature is completed.

Sections A–G are saved securely to our system. A separate, verified e-signature request (not a form field) will be sent to the email you provide above to complete your authorization.

Physician Health Assessment Form

Patient History & Physical — Sections A–F

Patient & Submitting Office

Section A — Diagnoses / Conditions

Central Nervous System Diseases (G00–G99)

Diseases of the Circulatory System (I00–I99)

Endocrine, Nutritional & Metabolic Diseases (E00–E89)

Diseases of Musculoskeletal/Connective Tissues (M00–M99)

Pulmonary / Respiratory Diseases (J00–J99)

Diseases of Digestive (K00–K95) & Genitourinary (N00–N99) Systems

Mental, Behavioral & Neurodevelopmental Disorders (F01–F99)

Other Conditions

Section B — Current Medications

Section C — Physical Examination

TB Screening & Vitals

Section D — Vital Parameters

Section E — Diet Orders

Section F — Risk Factors

Section G — Request for ADHC/CBAS Services

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