Patient Forms

Use the following forms to initiate admission to Bailey-Boushay House programs. For more information about the admission process or eligibility requirements, visit our Admissions page.

Inpatient Admission Forms

• Pre-Admission Screening and Resident Review (PASRR)
• Physicians Orders for Life-Sustaining Treatment (POLST)
• Standing Orders
• Advance Beneficiary Notice (ABN)
• Medicaid Participation Acknowledgment

Outpatient Admission Forms

• Outpatient Admission Form
• Outpatient Standing Orders

Chemical Dependency Admission Forms

• Chemical Dependency Admission Form

COVID-19

• COVID-19 Infection Prevention and Control Plan

Admission Office

If you have questions regarding patient forms or the admission process, please call the Bailey-Boushay House Admissions Office.

Phone: (206) 720-2305
Fax: (206) 720-2328