Guest Referral

Guest Referral Form

This referral can be submitted up to 30 days in advance of any scheduled appointment. This referral does not automatically guarantee eligibility or room availability. Families may call up to 48 hours in advanced to confirm room availability. Phone Number: (850) 477.2273
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Reason for Visit:
Physician Providing Care
HealthCare Facility
Admission or Appointment Date & Time (set as 12 am if not a scheduled time)

MonthDayYear
DateHourMinutesAM/PM Option
Anticipated Length of Treatment
Patient covered by Medicaid
Medicaid Plan
Select Medicaid Plan(s)
Medicaid / Humana Patient ID #
if patient does not have Medicaid, please type 000
Humana Patient ID #
Starts with "H"
Referring Staff Name
Referring Staff Contact Number
Format: (000) 000-0000.
Primary Parent/Legal Guardian

First NameLast Name
Best Contact Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Notes / Reason for stay (appt, surgery, in-patient)
Example: Multiple patients, Adoptive family, Child discharged, Traveling from afar, Etc.
Is this referral for a stay at our House location or Family Room?
Diagnosis
Medicaid Plan
Please assign guest a room
Should be Empty:

Guest Referral Form