Home Health Service Referral Form

**This completed form can be faxed Attn: Shayla Eubanks, Intake Coordinator at (612) 547-0556 or e-mailed to If you have questions call (612) 362-4452 or Marsha Claiborne at (612) 362-4434.

Referred by: / Phone number:

Personal Information

Client’s Name:
Social Security #: ______/______/______
PLEASE NOTE: FOR BILLING PURPOSES A COMPLETE SS# IS REQUIRED—REFERRAL WILL BE REJECTED WITHOUT IT. / Date of Birth:
______/______/______/ Working Phone #:
Address:
City: / Zip code:
Insurance/PMI(MA)#:
(Services are billed through MA, MHP, Medica, UCare) / Check here for Washington County Grant
Diagnosis (ICD-9 codes):
Health Concerns: / Allergies: NKMA

Contacts

Outpatient Psychiatrist’s Name: ______
Clinic/Hospital Name: ______Phone #: ______/ Client’s next appointment(if known):
______
Medical Doctor’s Name:______
Hospital/Clinic Name & Phone #:______
Behavioral Health Case Manager’s Name & Phone #:
CADI/TBI/Elderly Waiver Case Manager’s Name & Phone #:
Other Emergency Contact Name, Phone #, & relationship to client:

Reason for Referral

**Please note visit frequency will be 1x a week, unless otherwise specified:
EOW (Bi-weekly) Every 3 weeks Monthly/(Every 4 weeks)
Emergency Priority: (very serious) 1 2 3 4 5 (not serious)
MARK ALL THAT APPLY: Medication non-compliance Confusion with Medications History of overdose
Poor coping mechanisms Cognitive difficulties Poor follow-through w/refills, appts.
Other: ______

*Please answer the following questions if you are able; If collateral information (H&P), documentation) is available in can be included.

Is the client aware of and has agreed to receive Home Health services from our agency? No Yes
Date(s), Reason/Diagnosis of last inpatient hospitalization:
Is client currently on a commitment? No Yes (send documentation if possible) Expiration date: ______
Current Medications (Name of Medication, Dose, & Frequency)
**You may also attach a full medication along with this referral
Name: Dose: Frequency:
If the client receives a IM medication, indicate when it is next due and if client has this medication:
IM No Yes Next Due:______Client has this medication: No Yes
If client is currently inpatient, will the client be discharged with 30 Day Supply? No Yes
Are there any safety concerns, including Bedbug infestation? No Yes
*If yes, date of the residence'seradicationtreatment: ______
Other explanation: ______
Any history of violent behavior and/or criminal activity? (explain)
Any spiritual or cultural considerations? (explain)
Does the client require an interpreter? No Yes
If yes, for what language? ______
Is there a gender preference? No Yes
*If yes, please specify reason or circumstances: ______
Does the client have a spenddown? No Yes *(complete pg. 3 agreement for payment & indicate Rep Payee)
Does the client have a current Home Care Provider? No Yes
Name of Agency: ______Date services will be expected to end? ______
*(Please note this referral will be used for additional services requested)
ILS? No Yes * ILS services are pre-authorized through CADI/TBI Waiver Only
*If yes, indicate the goals and # of hours requested: ______
**CIP OFFICE USE ONLY (COMPLETED BY CIP HOME HEALTH/MH INTAKE COORDINATOR)
Date of Referral: Indicate the date that the complete written referral for initiation or resumption of care was received by the HHA.
__ __ / __ __ / ______
Date of Physician –ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services record the date specified.
__ __ / __ __ / ______

Client Agreement for Payment of Medical Spenddown

Client Name: ______Date: ______

I understand that I have a Medical Spenddown in the amount of $ ______per month.

Once this amount is satisfied, my medical psychiatrist services will be completely covered.

(This amount does not include any co-payments that I may have for medication).

I will use this service of a representative payee:

No

Yes

If yes, the Rep Payee is: Name: ______

Address: ______

______

I agree to pay CIP my monthly spenddown amount and I understand that if payment is not made to CIP; my services may be terminated.

______

Signature of Client Date

NA—Client does not have a spenddown

Return to:

Community Involvement Programs

1600 Broadway Street NE

Minneapolis, MN 55413

*Fax: (612) 547-0556

Revised 1/2014 1