Online Discharge Form Please call (517) 358-0113, or fill in electronic form below...   CLIENT INFORMATION   Client Name:     Sex:   Male Female   Address:     Date of Birth:     City:     Age:     State:     (H) Phone:     Zip:         Marital Status: Single Married Divorced Widowed   Legal Status: Responsible for self Power of Attorney Guardian       Live Alone: Yes No Client lives with:   Ambulatory Status: Mobile Disabled Bedridden   Post Accident Post Operation Other     EMERGENCY CONTACT INFORMATION   Contact Name:     Relationship:     Address:     (H) Phone:     City:     (W) Phone:     State:     (C) Phone:     Zip:     Email:       HEALTH PROVIDER / INSURANCE INFORMATION   Does the client have a primary health care provider? Yes No   Provider:       Address:     Phone:       Does the client have health insurance coverage? Yes No   Insurance:     Phone:       Policy #:       Is the client a United States Veteran? Yes No   If so, branch:       REFERRAL INFORMATION   Agency:     Phone:     Contact:     Email:     Diagnosis:     Urgent Needs:     CAPTCHA:       Code is Case Sensitive       Enter Code:

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