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Psychiatric Hospital Inpatient Admission Form 12357-B Riata Trace Parkway Suite 150 Austin Texas 78727-6422 TMHP CCIP Phone 1-800-213-8877 Fax 1-512-514-4211 I. Identifying information Medicaid Date Last name First name Middle initial Date of birth / Age Sex Date of admission Facility name Referral source Provider Commitment Type if applicable Effective Date Admitting MD Current living arrangements DPRS Time Name of contact person County MH Professional With parent s Group/foster home Judge...

How to fill out psychiatric hospital inpatient admission form

How to fill out Psychiatric Hospital Inpatient Admission Form

1. Read the instructions provided with the form to understand its purpose.
2. Fill out the patient identification section with accurate personal information.
3. Provide the patient's current address, phone number, and date of birth.
4. Complete the insurance information section if applicable, including policy number and provider details.
5. Detail the reason for admission in the medical history section, focusing on the patient's psychiatric condition.
6. List any medications the patient is currently taking, including dosages and frequency.
7. Include information on past psychiatric treatments and hospitalizations, if any.
8. Sign and date the form, along with a parent or guardian's signature if the patient is a minor.
9. Review all entries before submitting the form to ensure accuracy.

Who needs Psychiatric Hospital Inpatient Admission Form?

1. Patients experiencing severe emotional or psychological distress.
2. Individuals requiring stabilization for acute psychiatric symptoms.
3. Patients with a history of self-harm or suicidal ideation.
4. Individuals unable to care for themselves due to psychiatric illness.
5. Those whose treatment requires a controlled hospital environment.

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What is Psychiatric Hospital Inpatient Admission Form?

The Psychiatric Hospital Inpatient Admission Form is a document used to gather essential information about a patient who is being admitted to a psychiatric hospital for treatment. It seeks to capture the patient's mental health history, current condition, and any immediate care needs.

Who is required to file Psychiatric Hospital Inpatient Admission Form?

The form must be filed by the healthcare professional responsible for the patient's admission, typically a psychiatrist or clinical psychologist. Additionally, it may be completed by the patient's legal guardian or family member when applicable.

How to fill out Psychiatric Hospital Inpatient Admission Form?

To fill out the Psychiatric Hospital Inpatient Admission Form, the responsible party should accurately provide personal information about the patient, including identification details, medical history, current medications, and descriptions of the presenting problem. It is important to ensure that all sections of the form are thoroughly completed and any required signatures are obtained.

What is the purpose of Psychiatric Hospital Inpatient Admission Form?

The purpose of the Psychiatric Hospital Inpatient Admission Form is to facilitate the collection of necessary information required for the admission process, ensure appropriate care is provided based on the patient's history and needs, and comply with legal and regulatory requirements.

What information must be reported on Psychiatric Hospital Inpatient Admission Form?

The information that must be reported on the Psychiatric Hospital Inpatient Admission Form typically includes the patient's personal details, contact information, medical history, mental health assessment, current symptoms, risk factors, treatment preferences, and legal status if applicable.