Recuperative Care Referral Form Name of Referring Party * First Name Last Name Medical Record Number (MRN) Date of Birth * MM DD YYYY Gender * Male Female Transgender Other Patient Gender Expression He She They Other Primary Language * English Other Date of Referral * MM DD YYYY Referring Party Contact Information Referring Hospital/Facility * Name of Referring Party * First Name Last Name Referring Party Email * Referring Party Phone Number * (###) ### #### Patient Health Details Referring Party Phone Extension If Applicable (###) ### #### Reason for Most Recent Hospitilization * Does Patient Have Any Wound(s)? Yes No Patient History Physical Agression Mental Health Diagnosis Illegal Substance Use Probation/Parole Recent Surgeries in last 30days None of the Above Other Condition Patient History Other Conditions Please describe any other known conditions Does a Patient Have a Recent TB Test or Chest X-Ray? TB test are not required but are helpful, if available. Check all that are available to send via fax/email TB Test Chest X-Ray None Ambulatory Status and DME Device Used: Can Patient Accomplish ADL's? * Yes No Is the Patient Continent of Bowel Yes No Is the Patient Continent of Bladder? Yes No Additional Comments Is Patient in Isolation? * Yes No If Yes, Explain: How Many Days is Patient Authorized in Recuperative Care * 10 15 20 30 45 Is Transportation Needed? * Yes No Diet or Medication Allergies/Restrictions? * Yes No If Yes, Describe Allergies/Restrictions? Emergency Contact Name First Name Last Name Emergency Contact Phone Number (###) ### #### Patient Contact Number (###) ### #### Type of Insurance * If patient does not have insurance, please type none. Insurance Number Leave blank if patient does not have inusrance. Insurance Pay or Hospital Pay * Insurance Hospital Are All Admission Criteria Met? Yes No Is All Information on this Form Complete and Correct? Check here to confirm all information is correct and to verify that the hospital agrees to the terms of referral * All Information is correct Thank you!
