New Patient Referral Intake Form

New Patient Referral Intake Form

We appreciate your patient referral to Sanera Care.
Only required fields (*) are needed to submit a referral.
Providing additional information when available helps our team process referrals faster and move patients to care more quickly.

You can also send referrals via: EpicCare, CarePort/WellSky, Email: intake@saneracare.com
Name of Person referring Patient*
Full Name
Email*
Role/Title*
Add Job Title or Relationship if Self/Family Member/Caregiver
Referral Type*
Organization Name
Phone Number
Please enter a valid phone number.
Patient Information

Please enter the patient's information below. The more details provided, the sooner we are able to provide care.
Patient Legal Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Legal Sex*
Primary Contact Number:*
Secondary Contact Number:
Language*
In the last 30 days, was the patient recently discharged from a hospital, skilled nursing facility or acute rehab facility?*

YesNoUnknown
Discharge Date

MonthDayYear
Date
Primary Insurance*
If Medicare, indicate Part A or B
Primary Insurance Member ID/Policy #*
Is the preferred contact someone other than the patient?

YesNo
Preferred Contact Person (if not the patient)

Please provide the name and contact information for the individual we should contact to schedule an appointment if it is not the patient.
Name

First NameLast Name
Relationship
Contact Number
Would you like to provide additional patient details now?

YesNo
Please upload Patient Information: Facesheet, Past Medical History, etc if available.

Cancelof
SSN
Required for identity and insurance verification purposes only.
Email address:
Address

Street Address and Suite/Unit/Apt, if applicable

Street Address Line 2

City

Zip Code
State
County of Residence
Example: Los Angeles
Marital Status
Race
Ethnicity
Secondary Insurance
Secondary Member ID / Policy #
Upload Primary Insurance Card

Cancelof
Upload Secondary Insurance Card

Cancelof
Department
Please verify that you are human*
If you have any questions, please reach out. We are happy to assist.

P: (818) 418-3711 | F: (833) 764-5552 | E: intake@saneracare.com
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New Patient Referral Intake Form

Patient Information

Preferred Contact Person (if not the patient)