Refer A Patient | Harbor Recuperative Care

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*
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*
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

Max. file size: 20 MB.

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