Referral Form. Mailing Address City State Zip Code. Phone Pager PART A. Requested Placement Acute Rehabilitation Palliative Care

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1 Referral Form Admissions Office Fax Laguna Honda Blvd. San Francisco, CA Please fill out this form completely. Parts A, B, C may be completed by applicant, family member, physician, social worker, hospital discharge planner or community agency representative. Part D must be completed by a physician or other clinician. For a referral to rehabilitation services, please submit the most recent physical therapy and occupational therapy notes via fax, or postal mail. For a referral from a hospital, please submit 1) one week of current nursing notes and progress notes, 2) complete list of medications and dosages, and most recent history and physical with findings. Name of person completing form Relationship to Applicant Mailing Address City State Zip Code Pager PART A Applicant Last Name First Name MI General SNF SNF Rehabilitation Positive Care Respite - Dates Requested Placement Acute Rehabilitation Palliative Care Prior Living Arrangements Referring Facility Date of Referral Discharge Planner Pager Physician Pager Additional Contact

2 Laguna Honda Referral Form Page 2 of 8 Do any of the following exclusion factors apply to the person being referred? Communicable disease te: Laguna Honda may not have appropriate isolation quarters Person under police hold Mental Illness or developmental disability requiring an organized program of active psychiatric intervention, according to Title A of the California Administrative Code, paragraph 278.2(1)(b)(c) Needs some type of chemotherapy te: Laguna Honda cannot provide all types Ventilator dependent TPN (total parenteral nutrition) Enteral feeding Active medical problem requiring ICU care Primary psychiatric diagnosis without coexisting dementia or other medical diagnosis appropriate for SNF care Applicant s current level of care SNF Acute Acute Rehab Home Board & Care If applicant is in skilled nursing facility now, please also indicate acute dates. SNF Dates Acute Dates Please confirm that the person being referred meets basic admission criteria. Resident of City & County of San Francisco Primary diagnosis is a medical condition (not psychiatric) requiring skilled nursing facility care (MD verified) Existing physical or cognitive functional limitations require care that cannot be provided at a lower level (e.g. B&C, intermediate facility) Requires active daily rehabilitation on an in-applicant basis Needs ongoing rehabilitation aimed at improving functional status

3 Laguna Honda Referral Form Page 3 of 8 PART B Section 1 Applicant Demographics Age Sex Birth Date Ethnicity/Race SSN Marital Status Occupation Street Address City State Zip Code Primary Birthplace Alternate Religious Preference Primary Language English Speaking Smoker Nearest Relative Relationship Relative s Street Address City State Zip Code Emergency Contact Is applicant capable of making financial decisions? Unknown Please provide name and phone number of or current designated financial decision maker or name of person to make decisions in the event applicant becomes unable to make financial decisions: Name Is applicant capable of making Medical Decisions? Is applicant Conserved or has a DPOA? If yes, what type Name of Conservator or DPOA *Please include copy of Conservatorship, Durable-Power of Attorney or Medical Probate documents

4 Laguna Honda Referral Form Page 4 of 8 A. Government Benefits Part B Section 2 Pre-Admission Financial Data Medicare Eligible Number Part A Part B Part D Effective date Effective date Prescription plan Is the applicant enrolled in Medicare s hospice plan?, Revocation letter attached Medi-Cal Eligible Number Presumptive Medi-Cal Number *If Presumptive Medi-Cal Submit a copy of Medi-Cal Application with all verifications. Is the applicant enrolled in Medi-Cal hospice plan?, Revocation letter attached B. Private Insurance/HMO Carrier Name Policy/Group # Contact Name Name of Insured Union local, if applicable C. Income Monthly Amount Monthly Amount Source Source D. Assets Cash on hand Bank Funds Type(s) of Account(s) Bank(s) Securities (current value) Property - Location Assessed Value Amount Owed Other (describe)

5 Laguna Honda Referral Form Page 5 of 8 A. Diagnosis requiring SNF level of care PART C Section 1 Medical Diagnosis and SNF Need B. Allergies C. PICC D. Wounds Number Dressing Frequency E. NGT/PEG/ J-tube F. Weight Height G. Special Equipment (e.g. CPAP, BiPAP, wound vac, etc.) H. Does the applicant own and self-manage medical equipment outside of acute care? I. IV Antibiotics - Type Duration J. Date Last PPD Results K. Date Last CXR Results L. Advance Directive or Code Status Full Code DNR/DNI Comfort Undetermined M. Infections VRE MRSA TB C.Diff Other Location Treatment N. Immunizations Pneumonococcal Vaccine Date Influenza Vaccine Date Other Date

6 Laguna Honda Referral Form Page 6 of 8 A. Indicate appropriate number next to activity 1= independent 2= assist with device 3= assist with person 4= assist with person and device 5= totally dependent Bathing Feeding Walking Dressing Toileting B. Indicate Status C. Diet Transferring Turning and positioning Part C Section 2 Activities of Daily Living Bowel Incontinent Continent Colostomy Bladder Incontinent Continent Foley catheter or suprapubic tube Part C Section 3 Behavioral Issues A. Criminal Hx B. Drug trafficking or possession/use of weapons, illegal drugs or drug paraphernalia, Answer questions 3-7 based upon behavior over the past 10 days. C. Aggressive/Assaultive/Combative D. Intrusive Behavior E. isy/disruptive F. Elopement Risk

7 Laguna Honda Referral Form Page 7 of 8 G. Is applicant dangerous to self or others H. Psychiatric Condition Dx I. Suicidal Ideation Presently In the past J. Sexual Predation Registered sex offender If "yes to questions 1 10 above, please state number of incidents and describe. K. Alcohol History L. Drug Abuse: Type Currently using (at time of hospitalization) Past use M. Is applicant on restraints? Type O. Does applicant have a sitter? If yes, reason P. Are there past or present legal charges for any above behaviors? Describe

8 Laguna Honda Referral Form Page 8 of 8 PART D For referrals from board and care facilities and home, Part D must be completed by a physician or other clinician to assure accuracy and meet legal compliance. Please send additional medical information, if available, via the fax, or postal mail contact information appearing on the first page of this application. A signature is required whether part D is completed or attachments are provided. Primary Physician Physician Signature Alternate Contact Name Summary of Medical History/Problem List Medical History Previous Surgeries (dates and location) Disabilities (include sight, hearing, and ambulation) Current Medications Date of last physical and relevant findings

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