Refer A Patient | Harbor Recuperative Care

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*

US Resident or Citizen

Yes
No

MRN

Paying Hospital

Insurance

Ethnicity

Weight

Height

Hospice

Yes
No
Undecided

Admission Date

Projected DC Date

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*

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

Referral Submission Form

Patients Info

PATIENT STATUS

Fill In Section

Select A "Tier"

Recovering from chronic medical condition; minimal supervision; able to perform ADLs

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

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)

In hospice

Submitter's Info

Upload Documents

ALL SECTIONS MUST BE COMPLETED