Medicare Sign Up pack sample

EMERGENCY/DISASTERPLANFORHOMEHEALTHCAREPATIENTS W> E D Z' E / ͬ ^ ^dZ W Z W> / Ed ^ E ^h ^ (Keep this plan where it can be easily located/ DĂŶƚĞŶŐĂ ĞƐƚĞ ƉůĂŶ ĞŶ ƵŶ ůƵŐĂƌ ĂĐĐĞquŝďůĞ ) PLEASE CONTACT OUR AGENCY FOR ALTERNATE SERVICE OPTIONS IN CASE OF DISASTER WKZ & sKZ KEd d Z Eh ^dZ ' E / W Z KW /KE ^ E ^ Zs/ /K^ >d ZEK^ K E ^K ^ ^dZ Date/ &ĞĐŚĂ : __________ Information obtainĞĚ by: Client/Patient ( ůŝĞŶƚĞͬWĂĐŝĞŶƚĞ ) Caregiver ( WĞƌƐŽŶĂ ĞŶĐĂƌŐĂĚĂͿ ͗ Name / Nombre : ____________________ _ Relationship / relación : ___________ Phone: ____________ ůůĞƌŐŝĞƐͬ ůĞƌŐŝĂƐ͗ ප NKA ප Penicillin ප Sulfa ප Aspirin ප Iodine Ƒ Other: _______________________ ; DĞĚŝĐĂƚŝŽŶƐ͗ See medication scheduled/Ver el registro de medicinas ;ƉĂƌƚ ŽĨ ƚŚĞ ŵĞƌŐĞŶĐǇ WůĂŶͿ ^ƵƉƉůŝĞƐͬ D ( Suministros y ƋƵŝƉŽƐDéĚŝĐŽƐͿ Stethoscope (estetoscopo) , Thermometer (termómetro) , Prove Cover, Sphygmomanometer (esfimo) , Gloves (guantes) , Alcohol Pads (almohadillas de alcohol) , and scale (pesa) . Walker Cane W/C Commode Hospital Bed Diabetic Supplies Wound care Supplies Oxygen supplies Hoyer lift IV supplies Injection Supplies Foley Supplies Ostomy Supplies INR supplies Other: _____________________________________________ Special Needs/&ƵŶĐƚŝŽŶĂů >ŝŵŝƚĂƚŝŽŶƐ ;EĞĐĞƐŝĚĂĚĞƐ Fall precautions Bedbound Anticoagulant/Bleeding prec . Wound/Pressure ulcer prec . Infection control precautions Amputation WŚĂƌŵĂĐǇͬ &ĂƌŵĂĐŝĂ Name: __________________________________________ Phone: __________________________________________ ŽĐƚŽƌ Name: __________________________________________ Phone: __________________________________________ In Case of EmergencyNotifyto/ Ŷ ĐĂƐŽĚĞ ŵĞƌŐĞŶĐŝĂ ŶŽƚŝĨŝĐĂƌ Ă͗ Name: __________________________________ Relationship: ______________________ Phone: _____________________ Name: __________________________________ Relationship: ______________________ Phone: _____________________ Stay at home ( DĞ ƋƵĞĚĂƌĠ ĞŶ ĐĂƐĂ . Who will help with meds/ YƵŝĞŶ ůĞ ĂǇƵĚĂƌĄ ĐŽŶ ŵĞĚŝĐŝŶĂƐ ): _______________________________ Stay with family (Voy con familiares): Name/Address: ___________________________________________________________ Go to Shelter (Voy al Refugio) address: _______________________________________________________________________ Go to hospital, if medically necessary (Name): _______________________________________________________________ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ ĂƚĞ ͬ &ĞĐŚĂ WĂƚŝĞŶƚΖƐ ĂƚĂ ͬ ĂƚŽƐ ĚĞů WĂĐŝĞŶƚĞ͗ W/C bound Severe pain Incontinence Ambulation Hearing Endurance ĞƐƉĞĐŝĂůĞƐ͕ ůŝŵŝƚĂĐŝŽŶĞƐͿ Dyspnea Limited English proficiency . Primary language: ____________________________ ,ŽŵĞ DĞĚŝĐĂů ƋƵŝƉŵĞŶƚ ; ŽŵƉĂŹşĂ ĚĞ ĞƋƵŝƉŽƐͿ͗ ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ WŚŽŶĞ͗ ͺͺͺͺͺͺͺͺͺͺ EŽŶĞ hŶŬŶŽǁŶ Your nurse/ ĞŶĨĞƌŵĞƌĂ;ŽͿ (name/ ŶŽŵďƌĞ ) : _____________________________________ Phone/ dĞůĠĨŽŶŽ : ____________________ /Ŷ ƚŚĞĞǀĞŶƚŽĨ ŵĞƌŐĞŶĐǇ ;KƌEĂƚƵƌĂů ŝƐĂƐƚĞƌͿ/ǁŝůůͬ Ŷ ĐĂƐŽ ĚĞ ĞŵĞƌŐĞŶĐŝĂ ;Ž ĚĞƐĂƐƚƌĞ ŶĂƚƵƌĂůͿ zŽ͗ ^ĞƌǀŝĐĞ WƌŽǀŝĚĞĚ ;^ĞƌǀŝĐŝŽƐͿ ප Skilled Services ප Non Skilled Client’sEmergencyClassification/ ůĂƐƐŝĨŝĐĂcŝón ĚĞ ŵĞƌŐĞŶĐŝĂ ĚĞů ůŝĞŶƚĞ ͗ ;ĐŝƌĐůe one) ϭ Ϯ ϯ ϰ ;ƐĞĞ ďĂĐŬ ŝŶƐƚƌƵĐƚŝŽŶƐͿ ǁǁǁ͘ƉŶƐǇƐƚĞŵ͘ĐŽŵ (andador) (bastón) (silla de rueda) (cómoda) (cama de hospital) (suministros DM) (heridas) (grúa) (sueros) (inyecciones) (cateter) (ostomia) (cĂŝdĂƐ) Diabetic precautions (ŚĞƌŝdĂƐ,úůĐĞƌĂƐ) (oŝdo) Oxygen therapy, precautions Seizures precautions (ĐoŶvƵůƐŝoŶĞƐ) Weakness (débil) (problemas con el inglés) (lenguage primario) (oxígeno) /E ^ K& D Z' E z >>ϵϭϭ ; E ^K D Z' E zD / >> D Z > ϵϭϭͿ In Case of Nursing or related problem, please call our Agency (phone in the cover of you handbook) WƌŽďůĞŵĂƐ ĐŽŶ Ğů ^ĞƌǀŝĐŝŽ ůůĂŵĞ Ă ŶƵĞƐƚƌĂ ŐĞŶĐŝĂ ;Ğů ŶƷŵĞƌŽ ĞŶ ůĂ ĐƵďŝĞƌƚĂ ĚĞ ƐƵ ŵĂŶƵĂůͿ Client: ____________________________ _____ ___________ DZ η: __ __ __________ EŽmďƌĞ ĚĞů ĐůŝĞŶƚĞ DOB /Fecha Nac.: ________________ Age/ Edad : ____________ Address/ Dirección : ______________________________________________________ Living situation/ como vive : _________________________________________________________ Health Insurance, phone / Seguro Médico : ____________________________________________________________________________ Vision Impairments (problemas de visión) Service animal Obesity (obesidad) (dolor severo) (falta de aire) (resistencia) Mental Status /Depresion Hx ___ ___ ____________ Anxiety (Ănsiedad) (sangramiento) Speech (habla) TRANSPORTATION : Not needed, N/A Client will be driven by family Client will take public transportation (transportación pública) ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ Employee Signature/ &ŝƌŵĂ ĚĞů ŵƉůĞĂĚŽ Client will be picked up by special needs transportation service Other (Otro) : __________________________________________ (servicio de transporte para necesidades especiales) Oriented (orientado) Aspiration precautions (aspiración) Other (otros): ________________________________________ ____________________________________________________ ____________________________________________________ Disoriented (desorientado) Alert (alerta) Dementia (demencia) Forgetful (olvidadiso) Alzheimer I do not want assistance for transportation or shelter placement at this time. If I desire assistance in the future, I understand it is may responsibility to contact the Office of Emergency Management of my respective County. No deseo asistencia para transportacion o traslado a refugio en este momento. Si deseara asistencia en el futuro, entiendo que es mi responsabilidad contactar a la Oficina de Manejos de Emergencias de mi respectivo Condado. (No necesaria) (La familía lo llevará) Memory Impairm. sample