Information/Identification Page

Identification/Information Page – is used to identify the consumer and it includes the consumer’s personal information, Guardian information, diagnosis legal status, physicians/dentist/psychologist/psychiatrist/other, SSN, employment/Dayhab, emergency contact (s), the company or assigned nurse, Case Manager/administration office contact name and phone number, Pharmacy, HCL Model (such as “SL”) and LON.

This page should not be shared with unauthorized personnel.

Of course the “Identification/Information Page” will be on a full size sheet with the consumer’s required information. Each Provider/Company vary.

Consumer Name	Address	Phone Number
SSN	Medicaid Number	Emergency Contact#
HCL Model	LON	Guardian

Formats vary. Some Provider/company may use table form, some may just type it out in order with out the table and some may use both formats. The identification/information page is REQUIRED!

Also see, Identification/Information Page.






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