<p> Home Health Service Referral Form</p><p>**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.</p><p>Referred by: Phone number: </p><p>Personal Information Client’s Name: </p><p>Social Security #: ______/______/______Date of Birth: Working Phone #: ______/______/___ PLEASE NOTE: FOR BILLING PURPOSES A COMPLETE ___ SS# IS REQUIRED—REFERRAL WILL BE REJECTED WITHOUT IT.</p><p>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</p><p>Contacts</p><p>Outpatient Psychiatrist’s Name: Client’s next appointment(if ______known):</p><p>Clinic/Hospital Name: </p><p>______Phone #: ______</p><p>______</p><p>Medical Doctor’s Name:______</p><p>Hospital/Clinic Name & Phone </p><p>Revised 1/2014 1 #:______</p><p>Behavioral Health Case Manager’s Name & Phone #: CADI/TBI/Elderly Waiver Case Manager’s Name & Phone #:</p><p>Other Emergency Contact Name, Phone #, & relationship to client:</p><p>Reason for Referral</p><p>**Please note visit frequency will be 1x a week, unless otherwise specified: </p><p>EOW (Bi-weekly) Every 3 weeks Monthly/(Every 4 weeks)</p><p>Emergency Priority: (very serious) 1 2 3 4 5 (not serious)</p><p>MARK ALL THAT APPLY: Medication non-compliance Confusion with Medications History of overdose </p><p>Poor coping mechanisms Cognitive difficulties Poor follow-through w/refills, appts.</p><p>Other: ______</p><p>*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:</p><p>Is client currently on a commitment? No Yes (send documentation if possible) Expiration date: ______</p><p>Current Medications (Name of Medication, Dose, & Frequency) **You may also attach a full medication along with this referral</p><p>Name: Dose: Frequency: </p><p>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</p><p>Are there any safety concerns, including Bedbug infestation? No Yes *If yes, date of the residence's eradication treatment: ______Other explanation: ______</p><p>Any history of violent behavior and/or criminal activity? (explain)</p><p>Any spiritual or cultural considerations? (explain)</p><p>Does the client require an interpreter? No Yes</p><p>If yes, for what language? ______</p><p>Is there a gender preference? No Yes *If yes, please specify reason or circumstances: ______</p><p>Does the client have a spenddown? No Yes *(complete pg. 3 agreement for payment & indicate Rep Payee) </p><p>Does the client have a current Home Care Provider? No Yes Name of Agency: ______Date services will be expected to end? ______</p><p>*(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: </p><p>Revised 1/2014 3 ______</p><p>**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.</p><p>__ __ / __ __ / ______</p><p>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. </p><p>__ __ / __ __ / ______</p><p>Client Agreement for Payment of Medical Spenddown</p><p>Client Name: ______Date: ______</p><p>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).</p><p>I will use this service of a representative payee:</p><p>No </p><p>Yes</p><p>If yes, the Rep Payee is: Name: ______</p><p>Address: ______</p><p>______</p><p>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.</p><p>______Signature of Client Date</p><p>NA—Client does not have a spenddown</p><p>Return to: Community Involvement Programs 1600 Broadway Street NE Minneapolis, MN 55413 *Fax: (612) 547-0556</p><p>Revised 1/2014 5</p>