Article Structure
The Kaiser Work Note form serves a crucial role in the hospital admission process for expectant parents. This form not only collects essential personal information, such as the parent's name, birth date, and contact details, but also includes fields for the medical record number and expected date of delivery. It is imperative that the form is filled out completely to ensure that the admitting department has accurate information before the patient's arrival. Additionally, the form addresses financial aspects, reminding patients of potential hospital fees, deductibles, and co-payments due at the time of admission. Furthermore, it requests consent for the disclosure of important patient details during the hospital stay, allowing for smoother communication among caregivers. Parents are also encouraged to provide information about their ethnicity, marital status, and employment to support comprehensive care management. The form encompasses sections for both newborn information and Advance Health Care Directives, ensuring that all pertinent data is available upfront. Ultimately, the Kaiser Work Note form streamlines the admission process and aids healthcare providers in delivering informed and personalized care to patients and their newborns.
Kaiser Work Note Example
• • e
r *1 KAISER PERMANEJMTE® labor and delivery preadmission worksheet
Expected date of delivery:Medical Record Number:
Dear
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 |
|
C
o
Q E
o c
c o>
03 Q_
Ethnicity |
Marital Status |
|
|
|
|
|
|
|||
□ |
Hispanic / |
□ |
Common Law |
□ |
Married |
|
□ Single / Never Married |
|||
□ |
□ |
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 |
||
|
|
|
|
|||||||
Race |
|
|
|
|
|
|
|
|
|
|
□ Asian I Pacific |
|
|
□ Native American / Eskimo I |
|
||||||
□ Asian I Pacific |
□ White — Other White or European |
|
|
|
||||||
□ |
|
|
|
□ 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 |
|
|
|
|
|
|
|
|
c |
ADDRESS |
CITY |
STATE |
ZIP |
|
o |
|||||
o |
|
|
|
|
|
>S |
|
|
|
|
|
o |
SECONDARY CONTACT NAME |
|
RELATIONSHIP TO PATIENT |
|
|
E |
|
|
|
|
|
0) |
|
|
|
|
|
U) |
|
|
|
|
|
Emei |
HOME PHONE |
|
WORK PHONE |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
ADDRESS |
CITY |
STATE |
ZIP |
|
|
|
|
|
|
|
KAISER PERMAN ENTE® labor and delivery preadmission worksheet
Newborn Information
Ethnicity
Race |
|
Asian / Pacific |
Other |
Asian / Pacific |
Unknown |
White— Other White or |
|
Native American / Eskimo / |
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 |
||
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
OTHER INSURANCE COMPANY |
GROUP NO. |
|
INSURANCE ID |
|
|
|
|
|
|
|
|
INSURANCE COMPANY ADDRESS |
CITY |
|
STATE |
ZIP |
|
INSURANCE PHONE |
EFFECTIVE DATE OF INSURANCE COVERAGE |
|
|
|
|
|
|
|
|
|
|
Form Characteristics
| Fact Name | Details |
|---|---|
| Purpose | The Kaiser Work Note form is designed for expectant parents to provide essential information prior to labor and delivery at Kaiser Permanente facilities. |
| Completion Requirement | It is important to complete the form in its entirety. This ensures that the Admitting Department has all the necessary information for a smooth admission process. |
| Financial Obligations | Patients may be responsible for certain hospital fees, deductibles, copayments, or coinsurance. Payment is often required at the time of admission, and advance payments can be arranged with the Admitting Department. |
| Patient Information | The form requests various personal details, including last name, date of birth, marital status, and contact information, ensuring proper identification and communication. |
| Advance Directive | If the patient has an Advance Health Care Directive, a copy should be provided to the Admitting Department for incorporation into medical records. |
| Insurance Details | The form collects information about the health insurance coverage of the patient, including policy numbers and insurance provider details, to streamline billing and coverage verification. |
| Ethnicity and Race Data | To support health equity, the form includes sections to record the patient's ethnicity, race, preferred language, and other demographic information, which can help in addressing patient needs appropriately. |
Guidelines on Utilizing Kaiser Work Note
Filling out the Kaiser Work Note form is a straightforward process, but it’s essential to ensure that all the necessary information is filled in accurately. This will help streamline your admission and support any healthcare needs you may have. Here's how to fill out the form step by step.
- Begin with your last name, followed by your first name and middle initial.
- Next, provide your date of birth and, if applicable, your maiden name.
- Fill in your address, including city, state, and zip code.
- List your home phone, work phone, and cell phone numbers.
- Indicate your ethnicity by checking the appropriate box.
- Select your marital status from the provided options.
- If applicable, provide a clergy visit authorization by checking ‘Yes’ or ‘No’ and indicating what information you permit to be disclosed.
- Next, fill out your race by selecting the relevant option.
- Provide your religion, as well as your preferred spoken and written languages.
- Complete the information regarding your employer, including address, city, state, zip, and phone number.
- Indicate your employment status and occupation.
- Provide details for your primary contact and secondary contact, including their names, relationship to you, and their contact information.
- For newborn information, indicate the ethnicity and race using the provided options.
- If you have an Advance Health Care Directive, answer ‘Yes’ or ‘No’. If ‘Yes’, ensure you provide a copy to the admitting department.
- In the subscriber information section, fill out your name, relationship to patient, and relevant address and phone details.
- Include necessary details about any other insurance, such as the company and coverage information.
After you have filled out all sections completely, ensure you review the form for accuracy before submitting it to the Admitting Department. Having the correct information will assist in smooth communication and processing during your admission.
What You Should Know About This Form
What is the purpose of the Kaiser Work Note form?
The Kaiser Work Note form is designed for expectant parents to complete prior to labor and delivery. Completing this form helps ensure that the hospital has accurate and comprehensive information about the patient, which can facilitate a smoother admission process. It collects essential details such as personal identification, insurance information, and preferences regarding health care directives.
Who needs to fill out this form?
This form must be filled out by the patient who is about to deliver a baby. In cases where the patient may be unable to complete the form themselves, a family member or partner can assist provided they have the necessary information. It’s important that all relevant information regarding the expected delivery is included to avoid any delays during admission.
What information is required on the Kaiser Work Note form?
The form requires personal details including your last name, first name, date of birth, address, phone numbers, marital status, and ethnicity. Additionally, it asks for your employer’s information along with your occupation. If applicable, newborn information and advance health care directive details should also be provided. This comprehensive data is important for both administrative and healthcare purposes.
What happens if I forget to fill out a section of the form?
If any section of the Kaiser Work Note form is missed or left incomplete, the admitting department may need to reach out for additional information. This could lead to delays in your admission process. Therefore, it is advisable to review the form thoroughly before submission to ensure that all necessary areas are filled out completely.
Is it important to indicate my preferred language on the form?
Yes, indicating your preferred spoken and written language is essential. This information helps the hospital staff communicate effectively with you during your stay and ensures that language barriers do not hinder your care. It allows the medical team to provide services in a manner that is comfortable for you.
What should I do if I have an advance health care directive?
If you have an advance health care directive, it is crucial to inform the admitting department. You should bring a copy of your directive to be filed with your medical records. This document outlines your healthcare preferences and ensures that your wishes are known and respected during your hospital stay.
Are there any costs associated with my admission that I should be aware of?
Kaiser Permanente patients may have hospital fees, deductibles, or copayments that need to be settled at the time of admission. These costs can vary based on your insurance plan. It's recommended to contact the admitting department ahead of time if you wish to make a payment in advance or if you have questions regarding your financial responsibilities.
Can I provide my insurance information on this form?
Yes, there is a section for insurance details on the Kaiser Work Note form. You will need to provide the name of your insurance company, your policy number, and other relevant information. This allows the hospital to process your insurance claims and ensures that there are no issues with coverage when you arrive for your admission.
What should I do if I encounter a problem while filling out the form?
If you experience any difficulties while completing the form, it is a good idea to reach out to the admitting department for assistance. They can help clarify any questions or concerns you have, guiding you to ensure that all information is accurately captured. This can help alleviate any stress before your arrival at the hospital.
Common mistakes
When completing the Kaiser Work Note form, many individuals overlook important details that can lead to delays or complications. Here are ten common mistakes that people often make.
1. Incomplete Personal Information: One of the most frequent errors is not filling out all personal details. Missing vital information such as the last name, date of birth, or address can hinder the processing of medical records.
2. Incorrect or Missing Ethnicity and Race Designation: People sometimes skip the ethnicity and race sections or mark something incorrectly. These fields may seem optional, but they are crucial for various legal and medical reasons.
3. Failing to Provide Accurate Contact Information: It's important to ensure that all phone numbers are correct and detailed. Incorrect phone numbers can prevent the healthcare provider from reaching out if necessary.
4. Ignoring Advance Directive Information: Many people either do not check whether they have an Advance Health Care Directive or forget to provide a copy if they do. This can lead to confusion during critical care moments.
5. Forgetting Employment Details: Individuals often neglect to fill out the employment section fully. Providing complete employer details and occupational information helps establish a patient's insurance eligibility.
6. Failing to Include Insurance Information: It's vital to provide details regarding other insurance coverage, such as Medicare or Medi-Cal. Missing this information could result in billing issues later on.
7. Not Including the Newborn's Information: For expectant parents, omitting the newborn’s anticipated information is a common oversight. This data is necessary for hospital records and future healthcare needs.
8. Inconsistent Use of Names: In some cases, individuals might use different versions of names or might not include maiden names when applicable. This inconsistency can create challenges when verifying records.
9. Not Checking for Required Signatures: Some forget to sign the form or overlook additional authorization requirements. Missing signatures can delay admission or cause other administrative issues.
10. Rushing Through the Form: Finally, many people rush to complete the form, potentially leading to mistakes. Taking time to read through each section thoroughly helps prevent errors and ensures all information is accurate.
Documents used along the form
When preparing for a hospital admission or delivery, several forms and documents complement the Kaiser Work Note form. Each of these documents serves a specific purpose in facilitating the admission and ensuring that both medical and administrative processes run smoothly. Below is a list of commonly used forms and their descriptions.
- Admission Authorization Form: This document grants the hospital permission to treat the patient. It typically requires signatures from the patient or their legal representative, providing essential consent for medical care.
- Patient History Form: This form collects comprehensive information about the patient’s medical history, current medications, allergies, and previous surgeries. It assists healthcare providers in delivering tailored care during the admission.
- Insurance Verification Form: This form facilitates the confirmation of the patient’s insurance coverage. It usually requires details about the insurance provider and policy number to ensure that the hospital can process claims effectively.
- Advance Health Care Directive: Also known as a living will, this document outlines a patient's preferences for medical treatment in case they are unable to communicate their wishes. It is crucial for ensuring patient autonomy in healthcare decisions.
- Emergency Contact Information: This form provides details about individuals to be contacted in case of an emergency. It ensures that the hospital can reach the designated contacts if necessary.
- Medical Release of Information Form: Patients complete this form to authorize the hospital to share their medical information with specific individuals or healthcare providers. This is important for continuity of care.
- Pre-Operative Instructions: This document outlines essential guidelines for patients to follow before surgery, including dietary restrictions and medication management. Adhering to these instructions can impact surgical outcomes.
- Consent for Treatment Form: Required for various medical procedures, this form indicates that the patient understands and agrees to the risks associated with the treatment. It serves as a legal protection for both the patient and the healthcare provider.
- Payment Agreement Form: This document details any financial responsibilities the patient may have, including co-pays or payment plans. Understanding these obligations upfront can alleviate potential confusion later on.
Each of these forms plays a vital role in the hospital admission process, ensuring that the patient is well-informed, properly consented, and prepared for their care. Completing them accurately and returning them promptly can significantly enhance the entire experience for both patients and healthcare providers.
Similar forms
- Patient Admission Form: Similar to the Kaiser Work Note form, a patient admission form collects vital information such as personal details, medical history, and insurance coverage. Both forms aim to facilitate the patient intake process before medical services are delivered.
- Health Information Release Form: This document allows patients to authorize healthcare providers to share their medical information. Like the Kaiser Work Note, it ensures that the right protocols are followed when disclosing sensitive health information.
- Advance Directive Form: This form specifies a patient’s healthcare preferences in the event they become unable to communicate. It parallels the Kaiser Work Note in its focus on providing necessary information for optimal care management.
- Insurance Verification Form: Used to confirm a patient's insurance coverage, this form is essential for financial processing. Both documents require detailed personal and insurance information to ensure accuracy in billing.
- Consent for Treatment Form: Patients sign this document to grant permission for medical professionals to provide care. Like the Kaiser Work Note, it emphasizes informed consent and patients’ rights regarding their treatment.
- Pre-Admission Questionnaire: Similar to the Kaiser Work Note, this form gathers information about a patient's medical history and current health status before an upcoming procedure, thereby preparing healthcare providers effectively.
- Newborn Admission Record: This document records vital statistics and medical information about a newborn. Both forms require detailed demographic and health information to ensure the infant's wellbeing right from admission.
- Patient Registration Form: Essential for collecting basic information about a new patient, this form serves a similar purpose to the Kaiser Work Note by laying the groundwork for a patient’s file at a healthcare facility.
- Emergency Contact Form: This document identifies key individuals to be notified in case of emergencies. Similar to the Kaiser Work Note, it stresses the importance of having accessible contact information readily available for patient care.
Dos and Don'ts
- Do read the entire form carefully before filling it out.
- Do provide complete and accurate information for all required fields.
- Do ensure your contact details are up-to-date.
- Do check your responses for clarity before submitting.
- Don't leave any mandatory sections blank.
- Don't provide incorrect or misleading information.
- Don't hesitate to ask for help if you don’t understand a section.
Misconceptions
Here are eight common misconceptions about the Kaiser Work Note form:
- It's only for one-time use: Many believe the form is only needed for a single hospital visit. In fact, patients may need to complete it for multiple admissions or reasons.
- All sections are mandatory: Some think every section must be filled out. While most sections are important, certain areas may be left blank if not applicable.
- Payment must be made upfront: Some assume that they must pay the entire hospital fee at the time of admission. While upfront payments may be necessary, options for payment plans or arrangements often exist.
- The form is complicated: Many perceive it as overly complex. However, it is designed to be straightforward and user-friendly.
- Advance Health Care Directives are optional: Some patients think they can overlook Advance Directive information. Providing this information is essential for ensuring personal healthcare preferences are honored.
- Employer details are irrelevant: Some patients feel there’s no reason to include employer information. However, this data can assist with insurance processing and verification.
- Disclosing personal information is unnecessary: Certain individuals worry about sharing personal details on the form. This information is crucial for patient care and privacy regulations uphold its confidentiality.
- This form is only for women: Some mistakenly believe it’s only for female patients. The form is applicable to any patient involved in labor and delivery services.
Key takeaways
- Complete the Form Fully: Make sure to fill out every section of the Kaiser Work Note form. Missing information can lead to delays or complications during your admission.
- Understand Your Financial Obligations: Be aware that you may need to pay fees, deductibles, copayments, or coinsurance before being admitted. If possible, arrange to settle these payments in advance.
- Discuss Advance Directives: If you have an Advance Health Care Directive, provide a copy along with your form. This helps ensure your medical wishes are respected.
- Provide Accurate Contact Information: List primary and secondary contact details accurately. This ensures healthcare providers can reach your support network when necessary.
- Check Ethnicity and Race Sections: Selecting options for ethnicity and race helps the medical team provide culturally competent care. Ensure the information you provide reflects your identity.
Browse Other Templates
Llc in Tennessee Cost - The application not only updates information but also confirms the LLC's existence in the state.
Dhsh - Details about past assistance or household circumstances are also collected in the review.