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Referring Agencies: Please complete sections A, B and C of this form. Physician’s Offices: Please complete sections D and E of this form.A. Referring Agency Click here to enter text. Today’s Date: Click here to enter a date.Agency Representative Making Referral: Click here to enter text. Phone Number: Click here to enter text. Email Address: Click here to enter text.As the Referring Agency representative, I have communicated the service basics and referral process for the identified LifeCare Alliance services checked on this form to the below patient. ? Yes ? No The patient referenced on this form agrees to proceed with the assessment process for the identified service(s). ? Yes ? No If you answered no to either #1 or #2 above, provide background information so that we may proceed with initiating service: Click here to enter text.B. PATIENT INFORMATION Patient Name: Click here to enter text.DOB: Click here to enter text.Phone Number: Click here to enter text.Street Address: Click here to enter text.City, State: Click here to enter text.Zip: Click here to enter text.Emergency Contact: Click here to enter text.Emergency Contact Relationship: Click here to enter text.Emergency Contact Phone: Click here to enter text.Primary Insurance: Click here to enter text.Member ID #: Click here to enter text.Group #: Click here to enter text.Secondary Insurance: Click here to enter text.Member ID #: Click here to enter text.Group #: Click here to enter text.Patient’s Physician: Click here to enter text.Physician’s Fax: Click here to enter text.Physician’s Phone: Click here to enter text.Veteran ? Yes ? No If yes, please include a copy of patient’s DD214 with completed referral form, if possible.Franklin County Senior Options Recipient ? Yes ? No If yes, provide case manager’s name: ________________________ Services being received, if applicable: Click here to enter text.PASSPORT/MyCare Ohio Recipient ? Yes ? No If yes, provide case manager’s name: ________________________ Services being received, if applicable: Click here to enter text.This person receives home-delivered meals already. ? Yes ? No If yes, what is the meal provider? Click here to enter text.C. SERVICES BEING REQUESTED (check all that apply)Diabetic or Nutritional Counseling Supportive In-Home Services ? Medical Nutrition Therapy (MNT) ? Home-Delivered Meals*+ – Daily Hot ? Diabetes Self-Management Training (DSMT) ? Home-Delivered Meals*+ – Weekly frozen ? Safety/Wellness Check Only (no meal needed) Frequency: ? Daily ? Weekly ? Other ______ Verifying: ? Blood pressure ?Blood sugar ? Weight ? Other _________________ Report to referring agency when…Click here to enter text. ? Meal Preparation ? Home Repair Assistance Other Service – please provide as much detail as possible, explaining service(s) requested: Click here to enter text. *Please pick only one. +Meal customers must be home to receive the delivery and must sign/initial delivery receipt.D. PATIENT MEDICAL HISTORYICD DIAGNOSIS CODE(S): Click here to enter plete the below for Diabetic or Nutritional Counseling onlyMOST RECENT A1C RESULTS: Click here to enter text.DATE OF A1C TEST: Click here to enter a date.LABS:? Labs Enclosed ? No Current LabsMEDICATIONS:? RX List Enclosed ? No RX ListE. REFERRING PHYSICIAN (To be completed by physician’s office)Practice Name: Click here to enter text.Phone #: Click here to enter text.Fax #: Click here to enter text.Street Address: Click here to enter text.City, State: Click here to enter text.Zip: Click here to enter text.PCP/Referring Physician Name (please print): Click here to enter text.NPI #: Click here to enter text.Medicare #: Click here to enter text.PCP/Referring Physician Signature:Date Signed: ................
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