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.Format: (000) 000-0000.
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
Middle Name
Include Full Middle Name or Initial
First Name Used (Preferred Name)
If different than Legal First Name
Date of Birth

MonthDayYear
Date
Legal Sex
Mobile Number:
Format: (000) 000-0000.
Home Phone Number:
Format: (000) 000-0000.
Language
In the last 30 days, was the patient recently discharged from a hospital, skilled nursing facility or acute rehab facility?
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?
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
Format: (000) 000-0000.
Would you like to provide additional patient details now?
Please upload Patient Information: Facesheet, Past Medical History, etc if available.

Title all documents: Last Name, First Name - Date of Referral
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
CP Referral Code
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)