Home Healthcare Client Admission Record

Our Home Healthcare Client Admission Record Forms are professionally designed, fully customizable templates that assist home health agencies, caregivers, nurses, and healthcare providers in efficiently onboarding new clients. These essential documents help gather all necessary information to begin in-home care services, ensuring a smooth and compliant admission process.

Ideal for home health agencies, private caregivers, nurse practitioners, and case managers, these admission forms support proper documentation, care coordination, and HIPAA compliance.

What’s Included in the Admission Record Forms

Patient Information: 

Personal Details: Name, date of birth, address, contact information, and medical history

Insurance Information: Insurance provider, policy number, and billing details

Admission Details: 

Reason for Admission: Medical diagnoses, care requirements, and support services

Physician’s Orders: Current health status and specific care instructions

Care Needs and Requirements:

Type of Care: Skilled nursing, physical therapy, wound care, or personal care assistance

Duration and Frequency: How often and how long care is needed

Medical Equipment and Medications: 

Equipment Requirements: Oxygen, walkers, hospital beds, or other home-use items

Medication Management: List of medications and administration instructions

Patient Authorization: 

Consent to Release Information: HIPAA-compliant data sharing permissions

Signatures and Acknowledgment: Signed by the patient or legal representative

Contact Information: 

Home Health Agency Information: Contact details of the care provider

Referring Physician Contact: Physician’s information for coordination and follow-up

Key Features: 

• Fully Customizable: Editable in Microsoft Word or Google Docs

• Clear and Organized Structure: Easy to read and complete

• Legally Compliant: Supports HIPAA and patient privacy requirements

• Professionally Designed: Clean layout for a professional presentation

• Print and Email Friendly: Suitable for digital use or physical documentation

How It Works

1) Purchase the Home Health Care Admission Record Form Template

2) Customize it with your agency or facility details and services

3) Save, print, or email to begin the home health admission process

What You Will Receive Upon Purchasing:
• 1 Microsoft Word File: Instantly sent to your email. You can also access your files directly from your Etsy account (Profile > Purchases and Reviews).
• If you’re using a mobile device, please log into Etsy through the browser (www.etsy.com) as the Etsy app does not support file downloads.

Please Note: 

• This template is for personal use only and may not be resold or redistributed

• This is a digital product; no physical item will be shipped

• All sales are final due to the nature of digital downloads

By using this Home Health Care Admission Record Form Template, you can streamline your intake process, ensure compliance, and provide high-quality care from the start. This tool helps your agency stay organized, efficient, and professional in managing home care admissions.