(208) 473-2717


1. Review this form in conjunction with the paper/printed Admit Pack 

2. Please fill this form out completely.  Most fields are required fields. 

Reference Files:

Admit Pack Signature Pages PDF

Secondary Payer Worksheet PDF

Complete Admit Pack PDF

Home Health Admit Pack

Patient Sex

Does patient have health sense 65?

Does patient have True Blue?

Does patient have Secure Blue?

Does patient have Flexi Blue?

Does patient have Sterling?

Does patient have Humana?

Does patient have Medicare Complete?

Does patient have Secure Horizons Direct?

Does patient have Deseret Mutual?

Does patient have Regence Med Advantage?

Consent for Care - Check all that apply

Is the patient a participating member of and HMO (Health Maintenance Organization)

Expected Payer Source(s) for patient home care services include:

ADVANCE DIRECTIVES - Patient currently has:



Do you have a condition that restricts your ability to leave home except with the aid of supportive devices and assistance of another person?

Are absences from the home infrequent, of short duration and usually to receive medical care not available in the home?

Are there a combination of factors such as architectural barriers, stairs, cognitive or safety issues that result in an inability to leave home without assistance? (Psychiatric problems, cognitive deficits blindness, organic brain disorder, Alzheimer’s disease, etc. could qualify)

Is leaving home mentally contraindicated?

Patient has received the following document(s) from All Care Health Solutions

Signed a Durable Power of Attorney for Health Care

Signed a Living Will or Directive to Physicians

Patient authorizes All Care Health Solutions to release information and medical records regarding my medical health, mental health, and chemical dependency, as specifically requested, with respect to my treatment

Patient authorizes All Care Health Solutions and its representatives to have written and / or verbal contact with the following individuals: (Select any that apply, or leave blank)


Have you had a cough for two or more weeks duration?

Have you had Fever?

Has your cough been productive of sputum?

Has your cough been blood stained?

Have you had night sweats?

Have you had lethargy?

Have you had unintentional weight loss?

Do you or your family have TB now, or a history of TB?

Have you had Weakness?


Are any changes needed to the Medicare Secondary Payer Worksheet as listed in the hard copy?

Section A 1)

Section A 2)

Section A 3)

Section A 4)

Section B 1)

Section B 2) Type of accident?

Section B 3) Another party responsible?

Section C 1)

Section D 1) Age - Currently Employed?

Section D 2) Age - Spouse Currently Employed?

Section D 3) Group Health Plan on current employment?

Section D 4) Employer GHP employ more than 20 employees?

Section E 1) Disability - Currently Employed?

Section E 2) Disability - Spouse Currently Employed?

Section E 3) Group Health Plan on own or family members plan?

Section E 4) Covered under GHP of a family member other than spouse?

Section E 5) Employer GHP employ more than 100 employees?

Section F 1) ESRD - Do you Have GHP Coverage?

Section F 2) Have you received a kidney transplant?

Section F 3) Have you received maintenance dialysis treatments?

Section F 4) within 30 month coordination period?

Section F 5) entitled to Medicare on ESRD basis of age or disability?

Section F 6) entitled to Medicare based on ESRD?

Section F 7) Working aged or disability MSP provision apply?


Is patient on life support equipment?

Does patient require special transportation or equipment to leave the home?

MEDICAL SUPPLIERS (Check all that apply)

UTILITIES (Check all that apply)

Emergency Management Office (Check which applies)

Priority Level (Select One)


1. I have read the "Name of Beneficiary of Health Insurance" form and its contents, and further more acknowledge that if I have a Medicare HMO or Advantage Plan, I am responsible for any co-pays and/or coinsurance costs.

2. I have read the “Consent for Care”, “Patient Rights and Responsibilities”, which includes the State Home Health Hotline phone number, “Release of Information”, “Liability for Payment”, “Consent to Photograph”, “Statement of Patient Privacy Rights/Notice About Privacy”, “Privacy Act Statement – Health Care Records”, “Notice of Privacy Practices”, “Your Rights as a Patient to Make Medical Treatment Decisions”, “Advance Directives” and its contents.

3. I have read the "Medicare definition of Homebound" and its contents.

4. I have read “Advance Directive for Health Care”, “Patient Bill of Rights and HIPAA Information” and its contents.

5. I have read “Authorization to Release Information for Payment and Reimbursement Purposes” and its contents.

6. I have read “Authorization for Release of Medical Information” and its contents.

7. I have read “TB Screening upon Admission” and its contents.

8. I have read “Medicare Secondary Payer Worksheet” and its contents.

9. I have read the "Pinnacle Quality Insight survey notice" and its contents.

10. I have received the Quality Improvement Organization (QIO) contact information (Kepro: 888-317-0891).

11. I have read the "Emergency Preparedness Plan" and the "Admission/Transfer/Discharge Criteria".


If you click the Submit Button, and nothing happens, please scroll up to find the red highlighted fields.  Correct those required fields and re-try.  

Please allow up to 10 minutes for an admit pack to process after selecting the submit button