Patient Intake
Everything is on one page — scroll through each section, then sign the consent documents. Your progress saves automatically; if you step away, use the link we send to pick up where you left off.
Complete every section below on this one page. Required questions are marked; optional sections can be skipped. Your answers save automatically as you go.
How you found us
Tell us who referred you to Continuity Health Partners (CHP) or how you heard about our in-home care.
Choose the option that best describes how you found us.
If you found us on your own, you can leave this blank.
About the patient
Basic demographic information about the person receiving care.
Contact information
We'll use this to confirm your appointment and send care updates.
Type with or without dashes — any format works.
Type with or without dashes — any format works.
Address & residence
Our care team comes to you. Let us know where and how you live.
The address where you want care delivered.
Insurance
We accept Medicare, Medicare Advantage, Medicaid, and most commercial plans.
Start typing to search common plans, or enter your plan name.
Found on the front of your insurance card.
We use your Social Security number to verify insurance and to locate your coverage if the insurance information you provide is incorrect or incomplete. It is encrypted and stored securely.
Photo or scan. Helps us verify your benefits faster.
JPG, PNG, or PDF · or drag-and-drop here
JPG, PNG, or PDF · or drag-and-drop here
Identity documents
Uploading your ID helps us verify your identity and keeps your record accurate. This is optional.
Driver's license, state ID, or passport photo page.
JPG, PNG, or PDF · or drag-and-drop here
JPG, PNG, or PDF · or drag-and-drop here
Emergency contact
Who should we call in an emergency?
Type with or without dashes — any format works.
Type with or without dashes — any format works.
Healthcare advocate / DPOA / Guardian
If someone is authorized to make healthcare or financial decisions on the patient's behalf, please provide their information.
Type with or without dashes — any format works.
Your current doctor & care preferences
We coordinate with your existing physicians. This is optional but helps us provide continuity of care.
Type with or without dashes — any format works.
Used to request records and send clinical summaries.
Telehealth
Virtual visits let us see you between in-person appointments when needed.
Medications
List every medication the patient takes, or type "None".
Quick fill
Example: Metformin 500 mg twice daily. If the patient takes none, type "None". If you uploaded a medication list or MAR below, type "See attached".
Photo of your medication bottles or a printed list. Max 10 MB.
JPG, PNG, or PDF · or drag-and-drop here
Type with or without dashes — any format works.
Type with or without dashes — any format works.
Health & clinical information
The care team needs these answers before the first visit. If you are filling this out for someone else, answer for the patient.
Describe the main reason you are requesting a home visit (symptoms, follow-up needs, new problem, etc.).
Examples: diabetes, CHF, COPD, dementia, recent stroke or surgery. Type "None" if there are none.
Equipment, diet & goals
Optional, but it helps the provider prepare for the first visit.
Examples: short of breath walking, needs a walker and help, post-stroke weakness, dementia / fall risk.
Examples: stay at home, manage pain, avoid hospital admissions, comfort care.
Requested services
Select all services you are interested in. A referral specialist will discuss details with you.
Anything else you would like us to know before your first appointment.