NEW FORM

New Form

Referral Source
- Hospital
- ED
- Health
- Plan
- IPA
Attending Physician:
SW/CM:
Phone#
Email:
Nurse for Clinical Reviews:
Phone#
Email:
Patient’s Full Name:
DOB
Insurance: Health Plan & IPA (if any):
ID#
Gender:
- Male
- Female
- Trans
Date Admitted to Hospital/SNF:
Anticipated Discharge Date:
- Hospital Admission
- ER Visit
Primary Language:
Primary DX:
HX:
Length of Stay Authorized:
Responsible Payor:
Allergies:
Weight:
Height:
Surgery? If yes: Name of Surgeon:
Procedure Performed:
Date of Surgery:
Wounds? If Yes, Please provide:
- YES
- NO
Current Wound Care Report and Orders
- YES
- NO
Location
- YES
- NO
Stage
- YES
- NO
Can PT perform wound care?
- YES
- NO
Home Health Care will be coordinated
- YES
- NO
Recoup will provide wound care
- YES
- NO
Skilled Nurse/Home Health Check:
- YES
- NO
Physical Therapy
- YES
- NO
Wound Care
- YES
- NO
Other:
Mental Health:
- YES
- NO
Bipolar
- YES
- NO
Depression
- YES
- NO
Schizophrenia
- YES
- NO
Other On psych Meds?
- YES
- NO
Substance Abuse Issues?
- YES
- NO
Alcohol
- YES
- NO
Cocaine
- YES
- NO
Heroin
- YES
- NO
Methamphetamine
- YES
- NO
Requires Methadone Clinic
- YES
- NO
Independent with ADLs:
- YES
- NO
If No, explain:
Isolation?
- YES
- NO
If yes, explain:
DME? if Yes, Please check:
- YES
- NO
Walker
- YES
- NO
Cane
- YES
- NO
Crutches
- YES
- NO
Wheelchair
- YES
- NO
Oxygen
- YES
- NO
Wound Vac
- YES
- NO
Other
Continent of Bowel and Bladder:
- YES
- NO
Colostomy Care?
- YES
- NO
Catheter?
- YES
- NO
If Incontinent, can they change their own diapers?
- YES
- NO
Diabetic?
- YES
- NO
Requires Insulin
- YES
- NO
Oral Meds
- YES
- NO
If any “limitations or behavioral” challenges:
Cognitive Impairment
Incarceration/Probation/Parole Other
Follow Up Appointments Needed:

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Documents and Forms

Referral Form
Patient Information Document
Admission Criteria & Referral Process
Fill Out Referral Form
Transportation Form
Non-Discrimination Clause

Get in Touch

10900 S. Vermont Avenue, Los Angeles, CA 90044 Address

3570 E. Imperial Highway, Lynwood, CA 90262

(323) 676-1000

(323) 676-2000

info@horizoncenters.org

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