Please review the guidelines below prior to completing the form.
The Client Profile form can be downloaded in Microsoft Word format and filled out and then either emailed to medicaid@ca.inter.net or faxed in to (902) 477-0749.
Client Profile Guidelines
Client Information
– All information in this area must be complete. The
Residence Address must be the actual location of the home. The Mailing
Address is required for billing and communication purposes.
Emergency Dispatch Numbers – As of Jan 1,1999 local Police, Fire and Ambulance dispatch numbers are required. They can be found on the inside cover of the local phone book. If not listed, please call directory assistance for the correct phone numbers as no monitoring station is permitted to directly call 911. Please include your area code. In some cases there is one phone number that covers the Police, Fire and Ambulance station. Please ensure that we are provided with the correct phone number(s) as your life may depend on this information.
Responders – A complete name and at least one telephone number is required. An address is useful for communication purposes. Indicate if the Responder has a key to the residence. Three Responders are desirable but one is sufficient.
Responders should be willing and able to attend the client’s residence in less than 30 minutes.
Nearest Relative – Should be the relative or person that the client wishes to have notified in the event of a serious accident or illness.
Directions to Residence – For clients in cities or towns, indicate directions from the nearest major intersection. For clients in rural areas, provide detailed directions following the most likely route emergency vehicles would use.
Other Location of Key – Indicate instructions for emergency crews to find a key hidden outside the home. The key should be well hidden.
Instructions if No Key Available – Emergency crews will break into a home if they believe someone may need urgent help. As damage is likely, indicate the preferred method of forced entry to the home should it be necessary.
Physicians Name – Should be the clients regular physician.
Care Card Number – Not required but may speed hospital admission procedures.
Medic Alert Member ID – Not required but if the client is a Medic Alert member, ambulance and medical personnel may use it to get medical information on the client.
Medical Conditions
The following is a partial list of medical conditions. Any condition requiring continued treatment by a Physician should be noted.
|
|
Medications
Record all medications that fall under the following classes. The actual dosage is not required.
Anticoagulants Chemotherapy lmmunosuppressants Steroids
Beta Blocker Heart Respiratory Mood Altering
Allergies
The severity of any allergy should be noted.
Drugs: Aldomet, Aspirin, Codeine, Darvon, Demerol, Diabenase, Dilantin, Indocin, Nitroglycerin, Novacaine, Penicillin, Percodan, Quinine, Sulfa, Tetnus, Tetracycline, Theophylline, Thorazine, Tylenol, Valium
Foods: Dairy products, Nuts, Sea Food, Wheat products
Insects: Specify
Chemicals and Environmental: Specify any known allergies such as Iodine, Plastics etc.
Surgeries
List major surgeries that fall under the following categories:
|
|
Other Special Conditions
Record any other conditions or special circumstances that may affect medical care.
Contact Lenses Implants (specify) i.e. pacemakers, lenses
Dentures Participation in Clinical Studies
Developmental Challenges Organ Donor
Eyeglasses Prostheses (specify) i.e. heart valves, hips, knees
Hearing, Visual or Speech Impairment(s)