Client Face Sheet | Otik Healthcare Services

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8647 Cherry Lane, Laurel, Maryland, 20707

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Client Face Sheet

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Client Face Sheet

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Legal Name (Last, First, Middle) *

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Preferred Name

Date *

Individual's Agency Number

Social Security *

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Date of Birth *

Place of Birth

Marital Status

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Sex

Male
Female
Other

Other, please specify here

Religious Preferences

ADDRESS *

Address Line 1

City

State

Zip Code

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Telephone

Fax

Cell

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Medicaid Number

Medicare Number

Other Insurance

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Insurer

Policy Number

Legal Status

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Competent
Incompetent
Incompetend as determined by a Court of Law

Individual has a Legal Authorized Representative

Guardian, Authorized Representative, or Nest of Kin

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Guardian
Authorized Representative
Next of Kin

Name

Fax

Telephone

Cell

Address

Address Line 1

City

State

Zip Code

Care Management or Placing Agency

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Name

Telephone

Fax

Cell

Organization

Address

Address Line 1

City

State

Zip Code

Emergency Contact

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Name

Relationship

Telephone Number

Address

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Name

Relationship

Telephone Number

Address

Admission Record

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Date of Admission

Date of Service Initiated

Type of Service

Funding Source

Medicaid Waiver
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Discharge Record

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Date of Discharge

Reason for Discharge

Summary Completed *

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Entering New Program

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Name of New Program or Service Provider *

Address

Address Line 1

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State

Zip Code

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Telephone Number

Fax

Program or Service Provider Name

Name of Person or Agency Providing Services

Forwarding Address of the Individual

Address Line 1

City

State

Zip Code

Get in Touch

info@otikhealth.com

(+1) 410-567-1700

Admin Office:

8657 Cherry Ln., Laurel, MD 20707

Day Hub/CDS Day Program Center:

8647 Cherry Ln., Laurel, MD 20707

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