Kaiser Work Note – Fill Out and Use This PDF

The Kaiser Work Note form serves as a critical document designed to streamline the process of labor and delivery preadmission, ensuring that all necessary personal and medical information is collected efficiently from the expectant parent. It captures details such as the expected date of delivery, medical record number, personal information, insurance coverage, as well as any advance directive preferences. To simplify your admission process and help Kaiser Permanente prepare for your arrival, it is essential to complete this form thoroughly and return it to the Admitting Department.

Ensure your information is accurately recorded to facilitate a smoother admission process by clicking the button below to fill out the form.

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Kaiser Work Note PDF Details

Navigating the preparation for labor and delivery involves several crucial steps, among which filling out the Kaiser Work Note form, specifically designed as a labor and delivery preadmission worksheet, stands out. This comprehensive document serves an array of purposes, primary among them being the facilitation of a smooth admission process for expectant parents under the Kaiser Permanente healthcare umbrella. It requires detailed personal information, including expected delivery date, medical record number, demographic details, and contact information, which ensures that the hospital can provide tailored care according to the patient's medical and personal needs. Additionally, it outlines financial obligations such as hospital fees, deductibles, copayments, or coinsurance, providing an option for preadmission payments to ease the process. Furthermore, the form requests specifics on the newborn's information, advance directive information, and subscriber details to ensure that the hospital staff has all necessary information at their fingertips. By meticulously completing this worksheet and returning it to the Admitting Department, expectant parents can look forward to a more organized and less stressful admission process, paving the way for a focus on the joyous occasion of welcoming a new life.

Question	Answer
Form Name	Kaiser Work Note
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	kaiser doctors note for work, printable kaiser doctors note pdf, doctors note kaiser, kaiser doctors note pdf

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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
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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

How to Edit Kaiser Work Note Online for Free

The kaiser doctors note pdf filling in procedure is very simple. Our software enables you to use any PDF document.

Step 1: The following page contains an orange button stating "Get Form Now". Click it.

Step 2: So, you're on the form editing page. You may add information, edit present data, highlight specific words or phrases, insert crosses or checks, add images, sign the document, erase unneeded fields, etc.

All of the following parts will help make up the PDF form:

filling out kaiser work status report template step 1

In the box PHONE, EMPLOYMENT STATUS, OCCUPATION, PRIMARY CONTACT NAME, RELATIONSHIP TO PATIENT, HOME PHONE, WORK PHONE, ADDRESS, CITY, STATE, ZIP, SECONDARY CONTACT NAME, RELATIONSHIP TO PATIENT, HOME PHONE, and WORK PHONE provide the particulars that the system requests you to do.

Entering details in kaiser work status report template step 2

Identify the crucial data in the Ethnicity, Race, HispanicLatinoOther, Asian Pacific IslanderOther Asian, NonHispanic NonLatino, Asian Pacific IslanderOther, Other, Unknown, BlackOther Black, White Other White or, Native American Eskimo, European, Advance Directive Information, Do you have an Advance Health Care, and If yes please provide a copy to area.

Filling in kaiser work status report template step 3

The OCCUPATION, WORK PHONE, SUBSCRIBER NAME, RELATIONSHIP TO PATIENT, Other Insurante Information, ADDRESS, Male, Female, DATE OF BIRTH, HOME PHONE, CITY, STATE, ZIP, SUSCRIBER EMPLOYER, and EMPLOYMENT STATUS field is the place where each side can indicate their rights and obligations.

Finishing kaiser work status report template stage 4

End up by reviewing the following areas and completing them as required: INSURANCE COMPANY ADDRESS, CITY, STATE, ZIP, INSURANCE PHONE, EFFECTIVE DATE OF INSURANCE, and REV REVERSE.

Filling in kaiser work status report template stage 5

Step 3: When you have hit the Done button, your form will be accessible for transfer to any type of gadget or email address you identify.

Step 4: You could make copies of your file tokeep away from any type of possible future difficulties. You should not worry, we cannot reveal or track your data.

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