General Information

Please take a few minutes to fill out the questions below. The information obtained in this assessment will help us to decide any health care services you may benefit from. We will also work with you to develop a plan of care as needed. All information will be kept private as required by state and federal law except in cases of mandated reporting. Your information may be shared with your doctors and service providers. This will help in providing appropriateĀ care to you. Except as required by law, you have the right to agree or decline that this information beĀ shared.

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* 1. Date of HRS

Date / Time

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* 2. Member First Name

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* 3. Member Last Name

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* 4. Medicaid ID #:

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* 5. Date Of Birth

MM/DD/YYYY

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* 6. Age

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* 7. Mailing Address

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* 8. What is the best time of day and phone number to reach you?

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* 9. Do you have An Emergency Contact?

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* 10. Who is Completing this HRS

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* 11. Relationship to Member:

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* 12. Full Name of Person Completing HRS

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* 13. Method of Completion (This question should only be answered if Vendor Option was chosen)

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* 14. What is your preferred language:

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* 15. Gender/Sex:

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