Harold Mitchell
Valley Home Health Services
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Personal Information
First Name *
Last Name *
Date of Birth
Gender
—
Male
Female
Other
SSN (last 4)
Primary Diagnosis
Parkinson's disease
Address
Street Address
City
State
ZIP
Latitude
Longitude
Geocode
GPS coordinates used for caregiver geofence check-in (500m radius).
Contact & Emergency
Primary Phone
Secondary Phone
Email
Emergency Contact
Phone
Relationship
Physician
Primary Physician
Phone
NPI
Payer & Insurance
Payer Type *
Medicare
Medicaid
Dual
Private Pay
Insurance
Va
Medicaid ID
Medicare ID (MBI)
Insurance Company
Policy #
Group #
Authorization
Auth Number
Start
End
Approved Hours
Used: 0.00 hrs / 400.00 hrs (0%)
Billing Rate
$
/hr
Leave blank to use agency default rate.
Status & Directives
Status
Active
Inactive
Discharged
Hospitalized
Deceased
Admitted
Discharged
DNR on File
Advance Directive on File
Notes
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