ARMHS Program Referral Form

Home Health Service Referral Form

**This completed form can be faxed Attn: Shayla Eubanks, Intake Coordinator at (612) 547-0556 or e- mailed to [email protected] 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 #: ______/______/______Date of Birth: Working Phone #: ______/______/___ PLEASE NOTE: FOR BILLING PURPOSES A COMPLETE ___ SS# IS REQUIRED—REFERRAL WILL BE REJECTED WITHOUT IT.

Address: City: Zip code: Insurance/PMI(MA)#: Check here for Washington County Grant (Services are billed through MA, MHP, Medica, UCare) Diagnosis (ICD-9 codes): Allergies: Health Concerns: NKMA

Contacts

Outpatient Psychiatrist’s Name: Client’s next appointment(if ______known):

Clinic/Hospital Name:

______Phone #: ______

______

Medical Doctor’s Name:______

Hospital/Clinic Name & Phone

Revised 1/2014 1 #:______

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:

Revised 1/2014 2 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's eradication treatment: ______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:

Revised 1/2014 3 ______

**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:

If yes, the Rep Payee is: Name: ______

Address: ______

______

Revised 1/2014 4 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 5