Loading
Form preview picture

Get Triage Form Template

Desoto County Health Department Patient Triage Form INFORMATION YES ARE YOU A NEW PATIENT Last name NO First Middle Street address P. O. box Home Phone Number State City Emergency Contact Not Living With You Name Birthdate Social Security Number ZIP Code Phone Address OTHER INFORMATION STATUS Single Married INSURANCE INFORMATION Separated NONE Divorced GROUP Widowed ID HOUSEHOLD STATUS/EMPLOYMENT INFORMATION Name of Employer OTHER INCOME Child Support Retirement SSI AFDC/Food Stamps VA Benefits Unemployment Benefits Worker s Compensation Contributions from friends/relatives Student Loans None REASON FOR VISIT PLEASE LIST YOUR PRESENT HEALTH CONCERNS PROBLEMS OR SYMPTOMS AUTHORIZATION FOR TREATMENT I HEREBY CERTIFY THAT ALL INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE* I HEREBY APPLY FOR AND GRANT PERMISSION TO RECEIVE ALL NECESSARY MEDICAL TREATMENT AVAILABLE THROUGH THE DESOTO COUNTY HEALTH DEPARTMENT FOR MYSELF AND/OR MY FAMILY. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE DESOTO COUNTY HEALTH DEPARTMENT FOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE FOR SERVICES RENDERED. Client/Parent/Guardian/Responsible Party DATE YOU ARE REQUIRED TO COMPLETE THE FOLLOWING FOR A SLIDING SCALE DISCOUNT BASED ON TOTAL FAMILY INCOME* HEAD OF HOUSEHOLD INFORMATION Relationship Employed by Total Income Weekly Bi- weekly Monthly WAGE EARNER 2 LIST ALL HOUSEHOLD MEMBERS NAME SELF DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER. O. box Home Phone Number State City Emergency Contact Not Living With You Name Birthdate Social Security Number ZIP Code Phone Address OTHER INFORMATION STATUS Single Married INSURANCE INFORMATION Separated NONE Divorced GROUP Widowed ID HOUSEHOLD STATUS/EMPLOYMENT INFORMATION Name of Employer OTHER INCOME Child Support Retirement SSI AFDC/Food Stamps VA Benefits Unemployment Benefits Worker s Compensation Contributions from friends/relatives Student Loans None REASON FOR VISIT PLEASE LIST YOUR PRESENT HEALTH CONCERNS PROBLEMS OR SYMPTOMS AUTHORIZATION FOR TREATMENT I HEREBY CERTIFY THAT ALL INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE* I HEREBY APPLY FOR AND GRANT PERMISSION TO RECEIVE ALL NECESSARY MEDICAL TREATMENT AVAILABLE THROUGH THE DESOTO COUNTY HEALTH DEPARTMENT FOR MYSELF AND/OR MY FAMILY. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE DESOTO COUNTY HEALTH DEPARTMENT FOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE DESOTO COUNTY HEALTH DEPARTMENT FOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE FOR SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE FOR SERVICES RENDERED. Client/Parent/Guardian/Responsible Party DATE YOU ARE REQUIRED TO COMPLETE THE FOLLOWING FOR A SLIDING SCALE DISCOUNT BASED ON TOTAL FAMILY INCOME* HEAD OF HOUSEHOLD INFORMATION Relationship Employed by Total Income Weekly Bi- weekly Monthly WAGE EARNER 2 LIST ALL HOUSEHOLD MEMBERS NAME SELF DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER.

How It Works

triage sheet template rating
4.8Satisfied
47 votes

Tips on how to fill out, edit and sign Primary care triage template online

How to fill out and sign Triage sample online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Business, tax, legal and other documents need a top level of protection and compliance with the legislation. Our templates are updated on a regular basis in accordance with the latest legislative changes. Additionally, with us, all of the info you provide in the Triage Form is well-protected from leakage or damage through cutting-edge encryption.

The tips below can help you fill in Triage Form quickly and easily:

  1. Open the form in the feature-rich online editing tool by hitting Get form.
  2. Fill in the necessary fields that are yellow-colored.
  3. Hit the green arrow with the inscription Next to move from one field to another.
  4. Use the e-autograph tool to e-sign the document.
  5. Put the date.
  6. Read through the entire template to be sure that you have not skipped anything.
  7. Hit Done and download the new template.

Our platform allows you to take the entire process of submitting legal papers online. Due to this, you save hours (if not days or even weeks) and get rid of extra costs. From now on, complete Triage Form from the comfort of your home, place of work, and even while on the move.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Medical triage form template FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Triage Form

  • widowed
  • payable
  • bi
  • triage
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.