ENROLLMENT PROCESS

Please complete the referral form and send to GSC.  Your interest in becoming a patient with GSC will be reviewed for specific admission criteria.  Once approved to become a GSC patient we will send you your New Patient Packet by either email, snail mail, fax or you can pick it up at our office.

PATIENT INFORMATION

First Name *

Last Name *

DOB *


CONTACT INFORMATION

Your Email

Your Phone

Physical Address

City

State

Zip


Mailing Address (If different)

City

State

Zip


Relative Name *

Relation *

Phone*


REFERRAL SOURCE

Referral Source *:
Home HealthFamilySelfPhysicianOther


MEDICAL INFORMATION

Diagnosis *
DementiaCVAParkinson'sDiabetesCOPDCHFHTNCancerOther


DME *
CaneWalkerWheelchairOther


ADL's

Ambuliating: IndependentAssist

Bathing: IndependentAssist

Grooming: IndependentAssist

Toileting: IndependentAssist

Dressing: IndependentAssist


LADL's

Cooking: IndependentAssist

Cleaning: IndependentAssist

Laundry: IndependentAssist

Shopping: IndependentAssist

Transportation: IndependentAssist


Difficulty Leaving Home: YesNo

Homebound: YesNo

Recent Hospital Stay: YesNo


Does patient have advanced directive? YesNo

DNR: YesNo

POLST: YesNo


INSURANCE INFORMATION

Insurance: *
MedicareMedicaidSenior DimensionsSenior Care PlusProminenceVAOther

Notification of Health Plan To Change PCP: YesNo

Preferred MD