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Kaiser Work Note – Fill Out and Use

Kaiser Work Note is a program that allows you to create, organize and store checklists for projects. You can also share these lists with other people in your team or group.

By pressing the orange button directly below, you will access our PDF editor that enables you to edit this form efficiently. The application is created to help you to change any document you want with the use of our diverse toolbox. You can do it on pretty much any platform, anytime!

Kaiser Work Note Details

Kaiser work note form is a great way to keep track of your work hours. This form can be customized to fit your specific needs, and it is easy to use. The Kaiser work note form is perfect for both small and large businesses. It can help you keep track of employee hours, wages, and more. You can also use the Kaiser work note form to create invoices for customers. If you're looking for a reliable, easy-to-use work hour tracking tool, the Kaiser work note form is a great option.

This table holds specifics of kaiser work note. You can browse it before completing the form.

Question	Answer
Form Name	Kaiser Work Note
Form Length	2 pages
Fillable?	Yes
Fillable fields	97
Avg. time to fill out	19 min 58 sec
Other names	doctors note kaiser, return to work form, kaiser doctors note pdf, kaiser permanente doctors note

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• • e

r *1 KAISER PERMANEJMTE® labor and delivery preadmission worksheet

Expected date of delivery:Medical Record Number:

Dear Parent-to-be: To ensure accurate information, please complete this form in its entirety and return to the Admitting Department. As a Kaiser Permanente patient, you may have a hospital fee, deductible, copayment, or coinsurance which you are required to pay at the time of admission.

If you would prefer to make a payment in advance of your admission, please call or visit the Admitting Department. Thank you.

LAST NAME	FIRST NAME		MIDDLE INITIAL
DATE OF BIRTH	MAIDEN NAME
ADDRESS	CITY	STATE	ZIP
HOME PHONE	WORK PHONE	CELL PHONE

Q E

o c

c o>

03 Q_

Ethnicity		Marital Status
□	Hispanic / Latino—Other	□	Common Law		□	Married		□ Single / Never Married
□	Non-Hispanic/ Non-Latino	□	Divorced		□	Registered Domestic Partner		□	Widowed
		□	Legally Separated		□	Separated		□	Other
During your admission, we have			□	Name		□	Religion		Clergy visit?
your permission to disclose			□	Condition		□	No Information /		□	Yes
(check all applicable boxes):			□	Location / Phone			Confidential Admit		□	No
(check all applicable boxes):			□	Location / Phone					□	No
Race
□ Asian I Pacific Islander—Other Asian					□ Native American / Eskimo I Aleutian—Other
□ Asian I Pacific Islander—Other Pacific Islander					□ White — Other White or European
□	Black—Other Black				□ Other

□Unknown

	RELIGION	PREFERRED SPOKEN LANGUAGE		PREFERRED WRITTEN LANGUAGE
	EMPLOYER
	ADDRESS	CITY		STATE	ZIP

	PHONE	EMPLOYMENT STATUS		OCCUPATION

	PRIMARY CONTACT NAME		RELATIONSHIP TO PATIENT

tacts	HOME PHONE		WORK PHONE
tacts
c	ADDRESS	CITY		STATE	ZIP
o	ADDRESS	CITY		STATE	ZIP
o
>S
o	SECONDARY CONTACT NAME		RELATIONSHIP TO PATIENT
E
0)
U)
Emei	HOME PHONE		WORK PHONE
	HOME PHONE		WORK PHONE

	ADDRESS	CITY		STATE	ZIP

011116-001 (REV. 4-10)

KAISER PERMAN ENTE® labor and delivery preadmission worksheet

Newborn Information

Ethnicity

Hispanic/Latino—Other Non-Hispanic / Non-Latino

Race
Asian / Pacific Islander—Other Asian	Other
Asian / Pacific Islander—Other Pacific Islander	Unknown
Black—Other Black	White— Other White or
Native American / Eskimo / Aleutian—Other	European

Advance Directive Information

Do you have an Advance Health Care Directive? Yes No

If yes, please provide a copy to the Admitting Department.

Subscriber Information

NAME

RELATIONSHIP TO PATIENT

ADDRESS

CITY

STATE

ZIP

Male

Female

DATE OF BIRTH HOME PHONE

EMPLOYER

EMPLOYMENT STATUS

EMPLOYER ADDRESS	CITY	STATE	ZIP
OCCUPATION		WORK PHONE

Other Insurant:e Information

SUBSCRIBER NAME

RELATIONSHIP TO PATIENT

ADDRESS

CITY

STATE

ZIP

Male

Female

DATE OF BIRTH HOME PHONE

SUSCRIBER EMPLOYER			EMPLOYMENT STATUS

EMPLOYER ADDRESS	CITY		STATE	ZIP

OCCUPATION		WORK PHONE

MEDICARE CLAIM NO.	PART A EFFECTIVE DATE		PART B EFFECTIVE DATE

MEDI-CAL BENEFITS ID NO.	MEDI-CAL ISSUE DATE

OTHER INSURANCE COMPANY	GROUP NO.		INSURANCE ID

INSURANCE COMPANY ADDRESS	CITY		STATE	ZIP
INSURANCE PHONE	EFFECTIVE DATE OF INSURANCE COVERAGE
011116-001 (REV. 4-10) REVERSE

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Kaiser Work Note – Fill Out and Use

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