Florida Hospital Form PDF Details

The Florida Hospital form, specifically tailored for new patient intake within their oncology department, epitomizes the intricate blend of administrative efficiency and patient-centered care. It meticulously outlines the crucial steps for scheduling appointments with its specialized oncology team, comprising hematologists, medical and radiation oncologists, and surgical oncologists, ensuring that patients are seen within a stipulated 3-5 day window post-referral. Essential patient information, spanning demographics to detailed insurance data, is systematically collected to facilitate a streamlined care process. Moreover, the form lays out a framework for urgent appointments, diagnoses, and reasons for the appointment, underpinning the hospital's responsive approach to patient needs. Through the mandate of accompanying documents from the referring physician, it underscores the importance of a comprehensive medical history for informed care decisions. The backend processes involving care navigators, the integration with electronic health systems, and protocols for notifying the patient and receiving records form a complex ecosystem aimed at delivering personalized, timely care. This procedural thoroughness not only accelerates the referral process but also emphasizes the hospital's commitment to harnessing detailed patient information and coordination among various specialists to enhance the care trajectory for patients grappling with cancer.

QuestionAnswer
Form NameFlorida Hospital Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnew form v1 1 pdf, florida hospital discharge papers, hospital discharge papers, hospital intake v1 1 form

Form Preview Example

New Patient Intake Form V1.1 Every attempt is made to see the patient within 3-5 days from receipt of the referral request.

Schedule Appointment with:

 

Date/Time:

 

 

 

 

 

 

 

 

 

 

 

 

 

Dr. Seema Harichand-Herdt-Hematology Oncology

 

Dr. Michael Kelley-Medical Oncology

 

 

 

 

 

 

 

Dr. Ronald Krochak-Radiation Oncology

 

 

Dr. Christopher Windham-Surgical Oncology

 

 

 

 

 

 

 

 

Patient Information

First Name:

Address:

Last Name:

 

City:

 

 

 

 

State:

 

 

 

 

Zip:

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary

 

Secondary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

Phone:

 

 

 

 

Social Security #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

Cell

Work

Home

Cell

Work

Female

Male

Race:

 

 

 

 

 

Primary Insurance

 

 

 

 

 

Insurance Company Name & Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Subscriber’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy #:

 

 

 

Group #:

 

 

 

 

 

 

 

Subscriber’s DOB:

 

 

Subscriber’s SSN:

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary Insurance

 

 

 

 

 

 

 

 

 

Insurance Company Name & Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Subscriber’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy #:

 

 

 

Group #:

 

 

 

 

 

 

 

Subscriber’s DOB:

 

 

Subscriber’s SSN:

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Urgent

 

 

 

 

 

Appointment?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**Needs to be seen

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for Appointment:

 

 

 

 

Diagnosis

 

 

 

 

 

 

 

 

within 24-48 from

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

receipt of referral

 

 

 

 

 

 

 

 

 

 

 

 

 

New Diagnosis

 

Disease Progression

 

No

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2nd Opinion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referring Physician

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Care Physician

 

 

 

 

 

 

Name & Phone Number:

 

 

 

 

 

 

 

 

 

 

 

Name & Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please email the completed form to oncologyscheduling@fhmmc.org Questions: (386) 231-4050. In order to expedite the referral and allow us to see your patient in our 3-5 day timeframe, please send the below records to the above email or via fax (386) 231- 4001. A blank version of this form can be downloaded at www.floridahospitalmemorial.org/cancer.

 

 

 

 

 

 

 

 

 

 

 

 

Required Documents from Referring Physician Office

 

 

 

 

Demographics

History & Physical

Operative Report(s)

CT Scan(s)

Ultrasound(s)

 

Mammogram(s)

Recent Labs

 

 

Insurance Info

Path Report(s)

PET Scan(s)

MRI(s)

Bone Scan

 

Plain Films(s)

Office Notes

 

Patient Label

THIS SECTION TO BE COMPLETED BY THE CANCER CENTER SCHEDULER

PATIENT INFORMATION

 

First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPOINTMENT DATE/TIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CARE NAVIGATORS NOTIFIED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Breast Care Navigator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appt Date:

 

 

 

 

 

 

 

 

 

 

 

Appt Time:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lung Care Navigator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT AND APPOINTMENT ENTERED INTO SYSTEM

 

 

 

 

 

 

 

 

 

 

 

Radiation Oncology (Dr. Krochak)

 

 

 

 

 

 

Dr. Harichand, Dr. Kelley, Dr. Windham

 

 

 

MR #

 

 

 

 

 

 

FIN#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NextGen-Health Care Partners Oncology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NextGen-Health Care Partners

 

 

 

Cerner Scheduling

 

 

IMPAC

 

 

 

ARIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT NOTIFIED

 

 

 

 

 

 

 

 

NEW PATIENT PACKET GIVEN TO PT

 

 

 

Date/Time Patient Notified:

 

 

 

CCC General Pt Packet

CW-General CW-Breast

CW-GI

 

 

 

 

CW-Skin

CW-Soft Tissue

CW-Port Placement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailed

Date/Time:

 

 

 

 

 

 

 

 

 

 

 

Spoke directly to patient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spoke with patients family

 

 

 

 

 

 

 

 

 

 

Emailed

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECORDS RECEIVED FROM REFERRING PHYSICIAN

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

Pathology Report

 

 

 

Operative Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicable Consultation Reports

 

 

Bone Scan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

History & Physical

Most Recent Blood Work (Labs)

 

CT Scan

 

 

 

Time:

 

 

Initials:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PET Scan

 

 

 

 

 

 

MRI

 

 

Mammogram

 

Ultrasound

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHART CREATED

 

 

 

 

 

 

 

 

 

 

 

Radiation Oncology (Dr. Krochak)

 

 

 

 

 

 

Dr. Harichand, Dr. Kelley, Dr. Windham

 

 

 

Chart Label printed (Name & MRN)

 

 

 

 

 

 

 

 

 

 

Chart Label printed (Name & DOB)

 

 

 

 

 

 

Facesheet & Labels printed from Cerner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Records in chart

 

 

 

 

 

 

Records in chart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHART FORWARDED TO NURSING

 

 

 

 

 

 

 

 

 

 

 

 

NURSING RECEIVED

 

 

 

Date/Time:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initials:

 

 

 

 

 

Date/Time:

 

 

 

 

 

Initials:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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2. Once the last array of fields is done, you need to put in the necessary details in Policy, Group, Subscribers DOB, Subscribers SSN, Insurance Company Name Phone, Subscribers Name, Secondary Insurance, Policy, Group, Subscribers DOB, Subscribers SSN, Reason for Appointment, Urgent Appointment Needs to be, Diagnosis, and New Diagnosis nd Opinion so that you can proceed further.

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3. This third part is generally easy - fill in all of the empty fields in THIS SECTION TO BE COMPLETED BY, PATIENT INFORMATION, Patient Label, First Name APPOINTMENT DATETIME, Last Name, CARE NAVIGATORS NOTIFIED, Breast Care Navigator Lung Care, Appt Date, Appt Time, PATIENT AND APPOINTMENT ENTERED, Radiation Oncology Dr Krochak, Dr Harichand Dr Kelley Dr Windham, FIN, Cerner Scheduling PATIENT NOTIFIED, and IMPAC to complete this segment.

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4. The following subsection arrives with the following form blanks to focus on: DateTime Patient Notified, CCC General Pt Packet CWSkin, CWSoft Tissue, CWGeneral, CWBreast CWPort Placement, Spoke directly to patient Spoke, Mailed DateTime, Emailed Email Address, RECORDS RECEIVED FROM REFERRING, Pathology Report, Operative Report, Date, Time, Initials, and Bone Scan.

jackson memorial hospital discharge papers writing process described (portion 4)

5. The document should be wrapped up by filling out this area. Further you will see a detailed listing of form fields that have to be completed with accurate information to allow your form submission to be faultless: Chart Label printed Name MRN, CHART FORWARDED TO NURSING, Initials, DateTime, Notes, Chart Label printed Name DOB, DateTime, NURSING RECEIVED, and Initials.

Filling out segment 5 of jackson memorial hospital discharge papers

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