Home | Contact | About Us

Gaining Your Health Back At Home
Referral Intake Sheet
    No Current Episode   Current episode date:
Referral Date:

  DME

Facility/Client# Referral Source: Billing Source
Client’s Name:   Physician  Medicare
Address:   D/CPlanner   (name)  Medicaid
City, State, Zip:   Hosp  Work Comp
County:  Family/Friend/Self  Self Pay
Phone #:   Nursing Home  VA
SS# MC#  Other  Courtesy
Marital Status:        Does Client Live Alone? Yes no  Insurance
Other Individuals/Org. involved in clients care:        DDSD
SEX DOB AGE Allergies Language Spoken Emergency Contact (name,phone#,address)
 New Physician UPIN#:  New Physician UPIN#:
 Licensure Verified  Licensure Verified
Primary Physician Secondary Physician
Address Phone #
City,State, Zip Surgery DX/Date
Phone# Hospitalized Yes No  Other(SNF/REHAB)
Fax # Admit Date D/C DATE
Primary DX Hospital/SNF
secondary DX’s Work Related Yes No
Physicians orders (include refq., duration, and skill need)
V.O. Received: SOC Date: Therapy Received Part A Part B
SOC NURSE: Intake Nurse:
RN/CASE MGR ASSIGNED:
Services requested for SELF PAY: SN  CHHA  PT  OT  ST  MSW Homemaker/Companion
Frequency, days, Hours requested:
Other Pertinent Info:
BILLING INFO   Member ID
Policyholder’s Name: Policyholder’s SS#
Policyholder’s Employer Employer’s Telephone #
Insurance Co. Insurance Plan
Policy/Group # Group Name
Benefit Verification Telephone#
Directions to Clients Home:  
Not Accepted For Services Due To:
Referred To:
Referral Source Notified of Negative Referral:
Date Source notified:
                                     
   

for a printable copy of this form click here

Top | Home | Contact