MASS ASSOCIATION OF RESIDENTIAL CARE HOMES (MARCH)

HOSPITAL REFERRAL/INTAKE FORM
REFERRAL CONTACT AT HOSPITAL:
Name
Phone Number
Please enter a valid phone number.
FAX
Please enter a valid phone number.
Email Of The Referral Contact
example@example.com
REFERRING FACILITY:
Is consent granted by Patient/Guardian/ HealthCare Proxy?

YesNo

Rest Home Preference?
Click Here to view MHA REST HOME LISTING
List Potential Resident Rest Home Preference?

SECTION ONE:

PATIENT/POTENTIAL RESIDENT PERSONAL INFORMATION:
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MARITAL STATUS:

SinglePartneredMarriedSeparatedDivorcedWidowed
Gender
Primary Language

PAYMENT SOURCES
PRIMARY INSURANCE NAME & ID#
SECONDARY INSURANCE NAME & ID#
Choose Source Below
Other

SECTION TWO:

MEDICAL INFORMATION:
PRIMARY CARE PROVIDER NAME
Phone Number
Please enter a valid phone number.
MENTAL HEALTH PROVIDER NAME
Phone Number
Please enter a valid phone number.
MOST RECENT PHYSICIAN SUMMARY
LIST PRIMARY DIAGNOSIS:
MEDICATIONS/ANTIPSYCHOTIC MEDS
HCP/MOLST NAME
Additional Notes:

RESIDENT SUPPORTS
RELATIONSHIP
OTHER
Phone Number
Please enter a valid phone number.

IMPORTANT INFORMATION:
Admission to Level IV Rest Home Care requires potential candidate to undergo a physical at least 14 days prior to admission or up to 3 days after admission. It is also required to have the patient/potential candidate sign consents for antipsychotic medications, if applicable. A copy of a Health Care Proxy is also required to be shared with the Rest Home.

Please Note:

Each Rest Home has their own individual provisions and services independent to their facility. Please see Rest Home directory for specific services and amenities. This form is to understand the needs of the candidate and provide a starting point of contact for further assessment and considerations.

Please allow 3 business days for a response. For additional follow-up (no response) contact Ron Pawelski ronpawelski@gmail.com the assigned MARCH designee for further information.

Thank you for your referral.
PROJECTED DATE OF DISCHARGE:

MonthDayYear
Date
Should be Empty: