(323) 676-1000
Refer a Client
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Life at
Horizon
Our Services
Our Facilities
Los Angeles
Lynwood
Refer a Patient
Contact Us
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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(323) 676-1000