HOLA Recuperative Care: Referral Form

Patient First Name

Patient Last Name

Medical Record Number (MRN)

Date of Birth

Primary Language

Date of Referral

Referring Party Contact Information

Referring Hospital/Facility

Name of Referring Party

Referring Party Email

Referring Party Phone Number

Referring Party Phone Extension

If applicable

Patient Health Details

Reason for Most Recent Hospitalization

If Yes, Describe Wounds. What Stage Are the Wound(s)?

Patient History*

Check all that apply

Physical aggression

Mental health diagnosis

Illegal substance use

Probation/parole

Recent surgeries in last 30 days

None of the above

Other condition

Patient History: Other Conditions

Does Patient Have a Recent TB Test or Chest X-Ray? TB tests are not required but are helpful, if available.

Check all that are available to send via fax/email

TB Test

Chest X-ray

None

Ambulatory Status and DME Devices Used:

Additional Comments:

If Yes, Explain:

If Yes, Describe Allergies/Restrictions:

Emergency Contact Name

Emergency Contact Phone Number

Patient Contact Number

Type of Insurance

If patient does not have insurance, write none.

Insurance Number

Leave blank if patient does not have insurance.

Face Sheet & H&P's for Patient Please upload any relevant files. PDF & JPEG accepted

Add file

Please upload a file

Is All Information on this Form Complete and Correct?

Check here to confirm all information is correct and to verify that the hospital agrees to the terms of referral

All information is correct