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Referral Submission Form
Exclusion List
Patients Info
REQUIRED for all patients prior to acceptance to Harbor Recuperative Care:
· Cleared of all isolation precautions/exclusions
· Discharge orders including: Diagnosis, Dietary orders, follow-up scheduled appointments, Plan of Care and Discharge Prescriptions**
· If medical procedures are indicated, must have plan in place (ie: home health visits, clinic appointments, physical therapy visits, etc.)**
· Social Worker evaluation if one ordered by physician**
· If uninsured, we will need at least one month supply of all prescribed medications
**At the bottom of this form you will be able to attach and upload the required supporting documents mentioned above.
Patient Name
*
First
Middle
Last
Social Security #
Gender Identity
Birthdate
*
Month
1
2
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9
10
11
12
Day
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Year
2023
2022
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2019
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2012
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1928
1927
1926
1925
1924
1923
1922
1921
1920
US Resident or Citizen
Yes
No
MRN
Paying Hospital
Insurance
Ethnicity
Weight
Height
Hospice
Yes
No
Undecided
Admission Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
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5
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28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1991
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1988
1987
1986
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1984
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1982
1981
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1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Projected DC Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
LOS at RCC (est.)
*
PATIENT STATUS
(Indicate "Yes" or "No" to questions below)
Able to Self-Represent
*
Yes
No
Able to Self-Medicate
*
Yes
No
Hearing/Vision Impaired
*
Yes
No
Communicable Disease*
*
Yes
No
Tuberculosis
*
Yes
No
Isolation Precautions
*
Yes
No
Dementia / Alzheimer's
*
Yes
No
Hallucinations
*
Yes
No
Schizophrenic
*
Yes
No
Bipolar / Schizoaffective
*
Yes
No
Violent / Combative
*
Yes
No
Suicidal Ideation
*
Yes
No
Oxygen Dependent
*
Yes
No
IV Medications
*
Yes
No
Incontinence
*
Yes
No
Urinary Catheter
*
Yes
No
WC Bound (Permanent)
*
Yes
No
Is patient able to Transfer and/or complete ADL's Independently or needs assistance? If so, must be a Max 1-person assist.
*
Yes
No
What type of assistance is needed?
Ambulatory
*
Yes
No
Dialysis
*
Yes
No
Hypertension
*
Yes
No
Diabetes
*
Yes
No
Cancer
*
Yes
No
Homeless or Temporarily Homeless?
*
Yes
No
Legal Identification
*
Yes
No
Medically Compliant
*
Yes
No
Asthma / COPD
*
Yes
No
Quadriplegic
*
Yes
No
Is patient a Max 1-person assist?, Minimal Assist?, Stand by assist?, or Independent w/ or w/out Assistive device?
*
Yes
No
What type of assistance is needed?
Diaper Change Assistance-max 1-person assist?
*
Yes
No
Do they need to see a methadone clinic?
*
Yes
No
Fill In Section
If the answer is "YES" to any of the following questions a small window will open for you to explain a little bit more or to complete the answer to the question.
Cell Phone?
*
Yes
No
Enter Phone #
Pet / Auto
*
Yes
No
Please explain more about your Pet(s) or Automobile:
Assistive Device
*
Yes
No
Please explain more about your Assistive Device(s):
Substance Abuse
*
Yes
No
Please explain more about the Substance Abuse:
Home Health
*
Yes
No
Please explain more about the Home Health Details:
Spoken Language
*
SSI/SSDI/SS
*
GR / CalFresh
*
Wound
*
Insight
*
Judgement
*
Select A "Tier"
Please select the "Tier" that your client falls into.
Indicate Tier
*
TIER 1
TIER 2
TIER 3
TIER 4
An overview of the Tier's for reference:
Tier 1:
Recovering from chronic medical condition; minimal supervision; able to perform ADLs
Tier 2:
Recovering from an acute medical condition (such as wound, amputation, pressure sore); uses an assistive mobile device (such as wheelchair, FWW); minimal 1-person assist with ADLs; minimal Home Health for wound dressing changes
Tier 3:
Recovering from a chronic or acute medical condition & requires significant assistance with ADLs; Medical conditions requiring Home Health visits or frequent staff observation (IV antibiotics, O2, Incontinence, catheter care, colostomy care, dialysis)
Tier 4:
In hospice
Submitter's Info
Submitters Name
*
First
Last
Title
*
Referring Organization
*
Today's Date
*
MM slash DD slash YYYY
Submitters Phone
*
Submitters Phone Extension
Submitters Fax #
Submitters Email
*
*
I affirm that the above information is accurate to the best of my knowledge.
Signature
*
Upload Documents
Please use the following to upload supporting documents
Discharge Orders
including: Diagnosis, Dietary orders, follow-up scheduled appointments, Plan of Care and Discharge Perscriptions
Medical Procedures
: If medical procedures are indicated, must have plan in place (ie: home health visits, clinic appointments, physical therapy visits, etc.)
Social Worker Evaluation
and any other supporting documents...
Upload Documents
Drop files here or
Select files
Max. file size: 20 MB.
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