Clear Form

Hospital Admission/Discharge Form

Fax completed form to (952) 853-8705

Sender/Caller Information: □ Patient □ Hospital ✔

□ Provider
LUISA NATASHA VALERIA
Name: _____________________________ 63 9365728937
Phone: (______)______________ N/A
Fax: (______)______________
□ No □ Yes: ______________________________________
Does the patient have other insurance? ✔
4 25 4 25
2022 Time: _____:_____
Today’s Date: _____/_____/_______ PM
_____

Patient Information:
LLENARESAS
Patient: _______________________________ ZCHANISHKA GAYLE
_______________________________
Last First
N/A
HealthPartners Member ID # : __________________ 12 15.002000
Date of Birth: ____/____/______ □ Male ✔
□ Female
Admission Information:
4 15 2022
Admission Date: _____/_____/_______
4 25 2022
Discharge Date: _____/_____/_______
□ Home
Disposition: ✔ □ Expired □ Nursing Home Transfer □ Other Hospital Transfer
Admission Source:
□ ER/ED □ Direct □ Scheduled
✔ □ Direct Transferred From: _____________________________
□ Other ________________________________________
Admission Type, Bed, Unit (mark all that applies): ✔ In patient
□ Med/Surg □ ICU/CCU □ Mental Health □ Long Term Acute Care
□ Pediatric □ Swing Bed □ CH □ Detox □ Inpatient Acute Rehab
□ Maternity Delivery/DOB: _____/_____/_____ Nursery: □ Normal □ Level II □ Level III NICU
□ Twins □ Triplets
Baby: □Boy □Girl Name: Last________________ First______________ Hospital MRN: ___________
Baby: □Boy □Girl Name: Last________________ First______________ Hospital MRN: ___________
Baby: □Boy □Girl Name: Last________________ First______________ Hospital MRN: ___________
A90
ICD-10 Diagnosis Code: ___________________________________________________________________
8 - Other Procedure
ICD-10 Procedure Code (Inpatient): __________________________________________________________

Provider Information:
Zone Medical and Intervention Hospital Inc.
Facility: ______________________________________________ +63 915 698 5788
Phone: (______)___________________
Diversion Rd
Street: _____________________________________________ N/A
UR Dept: (______)___________________
Ligao
City: _____________________________________ Albay
State: ___________ 4504
Zip: ___________________
21-4813739
Facility Tax ID: ________________________________ LUISA NATASHA VALERIA
Provider Contact Name: _________________
RAMIREZ
Attending Physician: _______________________________ CLYDEN JAILE
_______________________________
Last First
63 9837465234
Phone: (______)___________________ N/A
Fax: (______)_____________________
San Jose
Street: _______________________________________________________________________________
Ligao
City: _____________________________________ Albay
State: ___________ 4504
Zip: ___________________
123-456-789
Physician Federal Tax ID: ________________________ N/A
or NPI #: ______________________________

Please include admission H&P information along with this form.

Updated 1/9/20