Hospitality House Referral w/Letter of Medical Necessity

1135 S. Victor Ave, Tulsa, OK 74104

P: 918-794-0088 | F: 918-794-0631
Medical Referral Form
Patient Name*

First NameMiddle NameLast Name
Patient Diagnosis*
Is the patient receiving inpatient or outpatient care?*

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

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

YesNo
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*

MonthDayYear
Date
Requested Check Out Date*

MonthDayYear
Date
Estimated Length of Stay *
Number of Days
Down Stairs Required?*

YesNo
Would the family like to use the Day Room?*

YesNo
Does the family have their own transportation?*

YesNo
Is the patient an infant in the NICU?*

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

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

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

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

YesNo
Date of Referral*

MonthDayYear
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 Provider*

Aetna Better Health of OklahomaHumana Healthy Horizons of OklahomaOklahoma Complete Health (OCH)Oklahoma Complete Health Children’s Specialty Plan(OCH-CSP)SoonerCare
Insurance Policy Number*
State*
Birthdate*

MonthDayYear
Date
Patient's Insurance Card

Browse Files
If available, please attach a copy of the patient's current insurance card Cancelof
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*

MonthDayYear
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?*

YesNo
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)*

Clear
Should be Empty:

Medical Referral Form