Client Referral

[{viewVars.title}]

Referral Date

[{viewVars.validations.referralDate}]

Referring agency

[{viewVars.validations.agency}]

Referring agency

[{viewVars.validations.organizationId}]

Referring agency point of contact name

[{viewVars.validations.agencyContact}]

Referring agency point of contact phone

[{viewVars.validations.agencyPhone}]

Referring agency point of contact email

[{viewVars.validations.agencyEmail}]

Secondary referral contact name

[{viewVars.validations.secondaryReferralContactName}]

Secondary referral contact phone

[{viewVars.validations.secondaryReferralContactPhone}]

Secondary referral contact email

[{viewVars.validations.secondaryReferralContactEmail}]

First Name

[{viewVars.validations.firstName}]

Last Name

[{viewVars.validations.lastName}]

Date of birth

[{viewVars.validations.dob}]

Gender

[{viewVars.validations.gender}]

Phone Number

[{viewVars.validations.phone}]

[{viewVars.validations.email}]

Medical Record Number (N/A if not currently hospitalized)

[{viewVars.validations.medicalRecordNumber}]

Please confirm that patient meets all medically supported shelter/respite criteria (must check all)

[{pr}]

Active Health Insurance Coverage?

[{viewVars.validations.hasActiveHealthInsurance}]

Active Health Insurance Provider

[{viewVars.validations.healthInsuranceProvider}]

If other, name insurance provider

[{viewVars.validations.otherInsuranceProvider}]

Medi-CAL member ID

[{viewVars.validations.mediCalMemberId}]

Medi-CAL CIN Number

[{viewVars.validations.mediCalCinNumber}]

Social Security Number

[{viewVars.validations.socialSecurityNumber}]

Can the client climb a flight of stairs

[{viewVars.validations.canClimbStairs}]

Current hospitalization status

[{viewVars.validations.hospitalizationStatus}]

Does the patient require isolation/quarantine for an infectious disease? If applicable, please describe

[{viewVars.validations.requiresIsolationDetails}]

Recent H&P

[{viewVars.validations.recentHP}]

View currently uploaded document Delete file

Current medication list

[{viewVars.validations.medicationList}]

View currently uploaded document Delete file

Please detail the medical necessity for admission to respite for this client, including goals of care during stay

[{viewVars.validations.medicalNecessityForRespite}]

Does this patient require an ADA accessible unit?

[{viewVars.validations.requiresAdaUnit}]

Is the patient independent for toileting and transferring?

[{viewVars.validations.independentForToileting}]

Can move self from bed to chair to commode and back without assistance?

Does the patient require oxygen?

[{viewVars.validations.requiresOxygen}]

List ALL Durable Medical Equipment required for the patient to independently care for self

[{viewVars.validations.medicalEquipments}]

Does the patient require hemodialysis?

[{viewVars.validations.requiresHemodialysis}]

Dialysis Center and schedule

[{viewVars.validations.dialysisCenterSchedule}]

Did the patient require isolation precautions during most recent stay?

[{viewVars.validations.hadIsolation}]

If yes, please detail 1. type of precaution (droplet, contact, airborne, etc) 2. diagnosis requiring isolation 3) current need for isolation if applicable

[{viewVars.validations.isolationDetails}]

Has the patient been under an involuntary hold during ANY part of this hospitalization?

[{viewVars.validations.hadInvoluntaryHold}]

Does the patient require home health services?

[{viewVars.validations.requiresHealthServices}]

If yes please provide accepting home health agency

[{viewVars.validations.homeHealthAgency}]

Primary care provider

[{viewVars.validations.primaryCareProvider}]

Behavioral health provider

[{viewVars.validations.behavioralProvider}]

Please add any other information relevant to the care of this patient

[{viewVars.validations.additionalCareInformation}]

Cardea Health requires the attestation of a medical provider (PA, NP or MD) that states that this individual has an acute diagnosis requiring recuperative care/or is at imminent risk of an avoidable hospitalization.

Name of Provider

[{viewVars.validations.provider}]

Clinic or Hospital

[{viewVars.validations.clinic}]

License Number

[{viewVars.validations.license}]

Phone Number

[{viewVars.validations.providerPhone}]

Thank you for your submission. We will contact you shortly.

[{viewVars.title}]

Agency Information

Patient Info

Attachments

Medical Necessity

Provider Attestation

Cardea Health requires the attestation of a medical provider (PA, NP or MD) that states that this individual has an acute diagnosis requiring recuperative care/or is at imminent risk of an avoidable hospitalization.