Hospitality House Referral w/Letter of Medical Necessity

1135 S. Victor Ave, Tulsa, OK 74104

P: 918-794-0088 | F: 918-794-0631

Patient Name

First NameMiddle NameLast Name

Patient Diagnosis

Is the patient receiving inpatient or outpatient care?

Does the guest needing to stay live 30+ miles from Tulsa?

Does the patient and caregiver needing to stay live 50+ miles from Tulsa?

Guest Name

First NameLast Name

Family's Phone Number

Area CodePhone Number

Family's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agency/Hospital Name

Hospital Floor/Room #

Requested Check In Date

Date

Requested Check Out Date

Date

Estimated Length of Stay

Number of Days

Down Stairs Required?

Would the family like to use the Day Room?

Does the family have their own transportation?

Is the patient an infant in the NICU?

Is the patient a Medicaid/Sooner Care/Sooner Select member for either primary or secondary insurance?

Is the hospital offering to provide meals for at least one parent?

Is at least one parent able to "room in" with the baby in the patient's current hospital room?

Is there a shower room available on the same floor as the patient that at least one parent can use?

Date of Referral

Date

Case Worker/Social Worker Name

First NameLast Name

Case Worker/Social Worker Email

example@example.com

Case Worker/Social Worker Phone

Area CodePhone Number

Any special notes we should know about the family?

Letter of Medical Necessity

All medicaid patients are entitled to receive Non-Emergency Transportation services to include meals, lodging, and transport as mandated by federal regulation 42CFR440170. To be eligible to utilize these benefits, medical necessity of the patient's treatment at your facility must be documented to support the request. However, not all medicaid patients who apply will meet the state criterion set forth for approval. While mileage is not the only determining factory, typically patients are eligible for this benefit if they reside more than fifty (50) miles from the medical facility. DHHS Review Board will take into consideration ALL requests that are under the mileage criterion based on the circumstances from the narrative you provide below. All information in this document is confidential and must by handled in accordance with HIPAA regulations.

Patient Information

Insurance Provider

Insurance Policy Number

State

Birthdate

Date

Patient's Insurance Card

Browse Files

If available, please attach a copy of the patient's current insurance card

Agency/Hospital Information

Agency/Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agency/Hospital Phone Number

Area CodePhone Number

Agency/Hospital Fax Number

Area CodePhone Number

Narrative/Justification

Confirmed Admit Date

Date

Gestational Age of NICU Patient at Birth

Justification Narrative for Escort/Attendant

Is it likely this recipient will be discharged to outpatient status for additional treatment before being discharged to home?

If yes, how many days will the patient by required to stay in the area prior to returning home after inpatient discharge?

Number of Days

I certify that it is necessary for this patient to receive treatment at the above facility and other requested services.

Staff Member Name/Title

Signature of Staff Member (MD, RN, CNS, LPN)

Medical Referral Form