PRS

EReferral Form

eReferral Form

Please complete this form to fill requirements for medical therapy staffing for your home care patient.

EReferral base on EInquiry

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Patient Contact Details

REFERRING AGENCY DETAILS

Please provide details on the referring company below.

Do you have a preferred clinician that you want to service your patient?

NO - Please assign qualified clinicans based upon the needs of my patient.

YES - I have a preferred clinican and I will provied the name in comments section below.

YES - I have previously provided SSS with a specifici list of clincians that can service our patients.

Client Company Name *

Select Client Company Name

Client Contact Name *

First Name

Last Name

Client Contact Email *

Please provide email where confirmation of referral may be sent.

PATIENT DETAILS

Please provide patient details below.

Patient Name *

First Name

Last Name

Patient Date of Birth

MM/DD/YYYY

Patient Type *

What is the Patient's age? *

Patient Age

Patient Gender *

Patient Address *

Street Address

City

State / Province / Region

Postal / Zip Code

Country

Patient Primary Phone *

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Referring Physician Name *

First Name

Last Name

Referring Physician Phone

Referring Physician Fax

Service Request

MANAGED CARE DETAILS

Primary/Secondary Diagnosis AND/OR Therapy Diagnosis *

Patient Insurance

Approved Number of Visits *

Authorization Start Date

Authorization End Date

Certification Period Start Date *

Certification Period Start Date

Certification Period End Date *

Certification Period End Date

REQUESTED DISCIPLINE DETAILS

PHYSICAL (PT/PTA) *

Select file Change

Upload File PHYSICAL (PT/PTA)

OCCUPATIONAL (OT/COTA) *

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Upload File OCCUPATIONAL (OT/COTA)

SPEECH (SLP/SLPA) *

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Upload File SPEECH (SLP/SLPA)

SOCIAL WORKER (LCSW/MSW) *

Select file Change

Upload File SOCIAL WORKER (LCSW/MSW)

REGISTERED NURSE (RN) *

What type of skilled nursing?

VOCATIONAL NURSE (LVN) *

What type of skilled nursing?

HOME HEALTH AIDE (CNA) *

SKILLED NURSING visit frequency ?

HOME HEALTH AIDE visit frequency ?

Timing of Evaluation ?

Scheduele Pref ?

Gender Preference ?

Language Pref ?

Which type of attachment is uploaded? *

485

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History & Physicals

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Orders

Select file Change

Last Visit Note

Select file Change

Evaluation

Select file Change

Others

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Additional Information/ Special Instructions

Review Your Entry

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REFERRING AGENCY DETAILS

Please provide details on the referring company below.

Referral Process:

Client Company Name:

Client Contact Name:

Client Contact Email:

Patient Name:

Patient Date of Birth:

Patient Type:

What is the Patient's age:

Patient Gender:

Patient Address:

Emergency Contact Name:

Emergency Contact Phone:

Referring Physician Name:

Referring Physician Phone:

Primary/Secondary Diagnosis AND/OR Therapy Diagnosis:

Patient Insurance:

Approved Number of Visits

Authorization Start Date:

Certification Period Start Date:

Authorization End Date:

Certification Period End Date:

PHYSICAL (PT/PTA):

OCCUPATIONAL (OT/COTA):

SPEECH (SLP/SLPA):

SOCIAL WORKER (LCSW/MSW):

REGISTERED NURSE (RN):

What type of skilled nursing?:

Is medication in the home?:

Is the vac placed?:

If not, will we be placing the vac?:

Is formula in the home?:

Which labs are we drawing?:

Are supplies in the home?:

Is their lab form in the home?:

Are supplies in the home?:

Please detail how supplies will be made available to patient/nurse for visit.:

VOCATIONAL NURSE (LVN):

What type of skilled nursing?:

Is medication in the home?:

Is the vac placed?:

If not, will we be placing the vac?:

Is formula in the home?:

Which labs are we drawing?:

Are supplies in the home?:

Is their lab form in the home?:

Are supplies in the home?:

Please detail how supplies will be made available to patient/nurse for visit.:

HOME HEALTH AIDE (CNA):

SKILLED NURSING visit frequency?:

HOME HEALTH AIDE visit frequency?:

Timing of Evaluation?:

Scheduele Pref?:

Gender Preference?:

Language Pref?:

Document Type:

Additional Information/ Special Instructions:

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