Referral Form | FM Recovery Healing & Restoration

Referral

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Patient Full Name:

First Name:

Last Name:

Patient Contact Number:

Date of Birth:

Referring Hospital/Facility

Date of Referral

Name of Referring Party

Phone of Referring Party

Name of Attending Physician

Emergency Contact Name

Phone Number

Type of Insurance

Insurance Number

Gender Expression

Reason For Most Recent Hospitalization

Discharge Medication/Dosage/Frequency

Any Food or Medication Allergies?

Any Diet Restrictions?

Additional Notes

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Admission Criteria

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Homeless, in the process of becoming homeless, or currently lives in an inappropriate setting for post-hospitalization recovery

New Field:

Yes

No

N/A

About to Complete All ADLS

Yes

No

N/A

Able to Properly and Safely Use DME Without Assist/Minimal Assist

No

Yes

N/A

Type of DME

Ambulation of at Least 50Ft Prior to Hospital or SNF Discharge (with or without dme)

Yes

No

N/A

Able to Self-Administer Medication with Minimal Staff Oversight?

Yes

No

N/A

Continent of Both Bladder and Bowels (If briefs or diapers are used, the patient must be able to change and maintain hygiene completely and independently)

Yes

No

N/A

Medically & Psychiatrically Stable?

Yes

No

N/A

Alert and Oriented (Name, Place, Date, and Situation)

Yes

No

N/A

Any Wounds?

Yes

No

N/A

Danger to Self or Others?

Yes

No

N/A

Any Specialized Care or Equipment: CPAP, Special Bed/Mattress, Wound Care, Detoxing, Etc. (Inform nurse prior to acceptance)

Yes

No

N/A

Please Attach

H & P

Facesheet

PT Notes

Psych Notes

Admission Criteria Met?

Yes

No

Is Transportation Needed?

Yes

No

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Referral

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Please Complete The Form Below

Referral

Questions? Contact Us

Get in touch