LCA Community Referral Form - Home » LifeCare Alliance

LifeCare Alliance ? Patient Referral Form

1699 W. Mound St ? Columbus, OH 43223 Phone: 614-278-3141 ? Fax: 614-278-3143 ? Email: referral@

? 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.

1. 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

2. 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.

Street Address: Click here to enter text.

DOB: Click here to enter text. Phone Number: 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. Primary Insurance: Click here to enter text.

Emergency Contact Relationship: Click here to enter text.

Member ID #: Click here to enter text.

Emergency Contact Phone: 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.

Client ID# ___________________ LifeCare Alliance RD's Name (if applicable)___________________

? 2017 LifeCare Alliance. All rights reserved. V.1711JS

LifeCare Alliance ? Patient Referral Form

1699 W. Mound St ? Columbus, OH 43223 Phone: 614-278-3141 ? Fax: 614-278-3143 ? Email: referral@

C. SERVICES BEING REQUESTED (check all that apply)

Diabetic or Nutritional Counseling Medical Nutrition Therapy (MNT) Diabetes Self-Management Training (DSMT)

Supportive In-Home Services Home-Delivered Meals*+ ? Daily Hot 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 HISTORY

ICD DIAGNOSIS CODE(S): Click here to enter text.

Complete the below for Diabetic or Nutritional Counseling only

MOST RECENT A1C RESULTS: Click DATE OF A1C TEST: LABS:

here to enter text.

Click here to enter a Labs Enclosed No Current Labs

date.

E. REFERRING PHYSICIAN (To be completed by physician's office)

MEDICATIONS: RX List Enclosed No RX List

Practice Name: Click here to enter text. Street Address: Click here to enter text. PCP/Referring Physician Name (please print): Click here to enter text. PCP/Referring Physician Signature:

Phone #: Click here to enter text.

Fax #: Click here to enter text.

City, State: Click here to enter text.

Zip: Click here to enter text.

NPI #: Click here to enter Medicare #: Click here to enter

text.

text.

Date Signed:

Client ID# ___________________ LifeCare Alliance RD's Name (if applicable)___________________

? 2017 LifeCare Alliance. All rights reserved. V.1711JS

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