Revival / Alpine Referral Form Referral Information:Does the Patient Have a PCP?*YesNoPatient Must Be Seen Within 48 Hours*Within 48 hours of normal business hours Mon- Friday 8-6YesNoLast seen*Within one monthWithin 2-6 monthsWithin 6-12 monthsGreater than one yearPCP Name:PCP Phone:PCP Email: PCP Fax:Date of Referral:* Home Visit is:*Routine Appt (7-10 Days)Urgent Appt (Screen for true urgent visits)Origin of Referral: ED OP In-Patient Community Hospital Readmission Score:Number of Visits Requested?*One Visit (Limited to Form Completion) - Includes M11Q, Transportation, Letter of Medical NecessityUp to Three Visits - Includes Transitional Care (Post hospital or SNF - Visits must be completed within 30 days), DME Orders, New Diagnosis, New Medication and/or Treatment, Wound CareOngoing Visits (every 4 to 6 weeks) - Patient Must be HomeboundSelect One*M11QTransportationLetter of Medical NecessitySelect One:*Transitional Care (Post Hospital or SNF)DME ordersNew DiagnosisNew Medication and/or TreatmentWound CareIs this a Healthfirst Insured Patient?*Yes (DOC is authorized to schedule a one time visit. Visit authorization from Healthfirst will be required for ongoing visits.)NoHas this patient been contacted within two business days of discharge?*YesNoIs a discharge summary availableYes (Please Upload)NoIs the Patient Homebound (requires taxing effort):*YesNoIs the Patient Being Seen by a Homecare Agency (CHHA/LHCSA)?*YesNoProgress Notes to Referrer:YesNoReferrer Fax:*Referrer Name:*Referrer Email: Referrer Type:PCPReferrerCare ManagerSocial WorkerCHHALHCSAProgress Notes to PCP:YesNoPCP Fax:*PCP Name:*Does the patient have an open case with APS (Adult Protective Services)?*YesNoIn a brief summary, specify reason for APS investigation.*Does the patient have have any mental illness/es?*YesNoSelect all applicable diagnosis from the following:*Anxiety DisorderDepressionSchizophreniaBipolar DisorderAlzheimer's DementiaDissociative DisorderPTSD (Post Traumatic Stress Disorder)AgorphobiaOtherPlease specify diagnosis:*Is the patient on prescribed therapy?*YesNoList all psychiatric meds currently prescribed:*Date last seen by a Mental Health Specialist:* Name of treating provider:*Treating provider contact information:*Is there a follow up appointment scheduled?*YesNoDate of next appointment: Is the patient currently under pain management care?*YesNoSelect all applicable diagnosis:*Neuropathic PainChronic Joint PainUlcer or Wound Related PainAcute PainMalignancy Related PainAuto ImmuneOtherPlease specify diagnosis:*Is the patient on prescribed medications?*YesNoList all analgesic therapy currently being prescribed:*Please list patients preferred pharmacy information in the notes section. Be sure to include the pharmacy name and telephone number.Does the patient need wound care?*YesNoAttach and Upload Clinical Documents:Please click on the 'Select files' button in the blue box below to select the clinical documents you wish to attach to this form.Attached Documents: Discharge Summary Labs / Diagnostics Results Advanced Directive Other Attach Clinical Documents: Drop files here or Accepted file types: jpg, gif, png, pdf, doc, xdoc. Patient Information:Patient Name:* First Last Date of Birth:* SS Number:Patient Phone:Patient Cell:Emergency Contact Name: First Last Emergency Contact Phone:Patient Lives Alone:*YesNoPatient Has Social Support:YesNoHome Address:Patient Primary Insurance Name:*Alpha CareArchCareEmblem Health (HIP and GHI) (All plans except for Healthcare Partners)Centers Plan for Healthy LivingGuildnet GoldGuildnet Gold Plus FIDAHealthfirst (All Plans including MLTC)HumanaMedicare Part BMetroplusMontefiore CMO IPA(MIPA)Self-PaySenior Whole Health (All plans except for MLTC)Village Care Max (All plans except for MLTC)VNS Choice MedicareVNSNY Choice FIDANone of the AboveThese are the only primary insurances accepted. *All secondary/supplemental insurance acceptedWe can not accept your referral. Doctors on Call can only accept patients who are covered by one of the insurance plans listed above.Patient ID/Policy-Group #:Patient Secondary Insurance Name:Secondary ID/Policy-Group #:Does patient have healthcare proxy?*YesNoName:RelationshipPlease upload healthcare proxy form if available.Patient Referred By:Name:* First Last Title:*Organization:*Phone:*Email:* Fax:Reason for DOC Visit:Check all options that apply: History of Multiple ED / Hospital Admissions Hospital Transitional Care Progressive Chronic Illness Complex Geriatric Care Homebound Status, Frailty Medication Reconciliation Alzheimer's / Dementia Anti-Coagulation Non-Adherence Heart Failure - AHA Class III / V Has Not Seen PCP > 6 Months DM HTN ERSD COPD / Asthma Cancer Cellulitis Infection Pain Assessment Falls Rehabilitation Needs Wound Care Orthotic/Prosthetic Evaluation, and Functional Assessment Neurological: CVA MS ALS Care of Older Adult Screens: Physical Activity Incontinence Fall Assessment Other Reason for DOC Visit:Gait / Ambulatory Status of the Patient: *Check option that applies:* Homebound Assisted Device Unassisted Teaching / Education Required by Patient:Check all that apply: Medication Management Self-Care ADL’s Fall Prevention Home Safety Blood Pressure Diabetic: Insulin Administration Glucometer Wound Care: Decubiti Venous Arterial Nutrition / Diet: DM Low Salt Cardiac Other Other Diet:Counselling: Diabetes Smoking Alcohol Giat Training Depression Weight Management Other Other Counselling:Patient Evaluation Required for Additional Services:Check all that apply: CHHA MLTC Hospice DME Skilled Nursing PT OT SW Nutrition Housing Finances (Fixed Income) Health Literacy Social Isolation (No Caregiver Support) HHA > 12 Hours Daily Medicaid Application Orthotics/Prosthetics Form Completion:Check form(s) that need to be completed: Face to Face M11Q CMS 485 Other Comments:UntitledEmailThis field is for validation purposes and should be left unchanged.