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Home Health Intake Form

Asks about homebound status justification, hospital discharge information, and primary diagnosis & orders. Built for medicare-certified home health agencies.

Questions
17
Pages
2
Time
about 4 min

Includes

  • E-signature
  • Medication list
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Your practice

Home Health Intake Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Medicare-certified home health agencies
  • Visiting nurse services and home-based primary care
  • Post-acute transitional care and hospital discharge programs
  • Home health intake and referral coordination offices

What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Email AddressEmail
  5. Homebound Status JustificationLong Text

Page 2 · Additional details

  1. Cognitive & Communication StatusLong Text
  2. Medication Management AssessmentMedications
  3. Skilled Service NeedsLong Text
  4. Caregiver Availability & SupportLong Text
  5. Home Safety AssessmentLong Text

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Home Health Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

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Questions

Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.

Yes. You can add, remove, reorder, or reword any of the 17 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Yes. The Home Health Intake Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

Add the Home Health Intake Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

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