Care Connect Internal Referral Form |

CC Internal Referral

Step 1 of 3

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ServicePoint Release of Information: Care Connect+ is a participating provider of vital services that utilizes ServicePoint, a project of the Care Connect Information Network (CCIN). ServicePoint participating agencies work together to provide services to persons and families in need. When you request or receive services, we may collect data about you and your household such as: Your name, date of birth, contact information, gender, education, benefits, employment, income, general health, disability, living situation and service needs. The information you provided is confidential and will only be used to assist you in accessing appropriate resources unique to your situation. We enter your data in a computer program that is protected by passwords and encryption technology. By sharing your information with other agencies, you may be able to avoid being screened again, get services faster, and minimize how many times you have to tell your “story.” You also help agencies document the need for services and demonstrate that funding is needed. By submitting this form you are granting permission to Care Connect+ to enter the information into the Care Connect Information Network and to share with the agencies that may provide your assistance. Your consent is valid for 90 days after submission.

Agree(Required)

I agree to share my information

Referral Source(Required)

Name of Referrer(Required)

Phone Number of Referrer(Required)

Please type your full name and insure that it is spelled correctly to proceed. If you have not seen the "Next" button and are an authorized user please reach out to Dannette Korfhage: [email protected]

Client Name(Required)

First Last

Is this client currently homeless?(Required)

Yes

Do they have an address?(Required)

Yes

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

MRN

Hospital Room Number

Estimated Discharge Date

MM slash DD slash YYYY

Does the client have a form of communication?(Required)

Yes

Is the client a veteran?(Required)

Yes

Client Phone Number(Required)

Client's Primary Care Physician

Does the client have insurance?(Required)

Yes

Insurance Type(Required)

Did you schedule a follow-up appointment with a PCP/Specialist?(Required)

Yes

What date is their follow-up?(Required)

MM slash DD slash YYYY

Did you schedule transportation for their follow-up?(Required)

Yes

Is the client at high risk for readmission in the next 30 days?(Required)

Yes

Has the client readmitted to the hospital in the last 30 days?(Required)

Yes

Reason for Referral (Select all that apply)(Required)

Comments

CC Internal Referral

Step 1 of 3

33%

Agree(Required)

I agree to share my information

Referral Source(Required)

Name of Referrer(Required)

Phone Number of Referrer(Required)

Please type your full name and insure that it is spelled correctly to proceed. If you have not seen the “Next” button and are an authorized user please reach out to Dannette Korfhage: [email protected]

Client Name(Required)

First Last

Is this client currently homeless?(Required)

Yes

Do they have an address?(Required)

Yes

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

MRN

Hospital Room Number

Estimated Discharge Date

MM slash DD slash YYYY

Does the client have a form of communication?(Required)

Yes

Is the client a veteran?(Required)

Yes

Client Phone Number(Required)

Client's Primary Care Physician

Does the client have insurance?(Required)

Yes

Insurance Type(Required)

Did you schedule a follow-up appointment with a PCP/Specialist?(Required)

Yes

What date is their follow-up?(Required)

MM slash DD slash YYYY

Did you schedule transportation for their follow-up?(Required)

Yes

Is the client at high risk for readmission in the next 30 days?(Required)

Yes

Has the client readmitted to the hospital in the last 30 days?(Required)

Yes

Reason for Referral (Select all that apply)(Required)

Comments

Assistance with Medication Adherence and Accessibility
Decline in Ability to Perform Activities of Daily Living/Social Needs
ALF/SNF/Other Placement
Food Insecurity
Housing Insecurity
Medicaid/SNAP/Entitlement Program
Mental Health Resources/Support
Chronic Condition Management/Education
Non-Compliance with Treatment Plan
Long Range Planning/Decision Making
Establish In Home Support - Requires Supervision
Health Insurance Information
Arrangement of Transportation
Establish PCP/Specialist
Facilitate Discussion of Advanced Directives
Substance Abuse Resources/Support
Chronic Illness Present with NO Insurance or Access to Healthcare
Tutschek Fund
DME
NICU Patient

Assistance with Medication Adherence and Accessibility
Decline in Ability to Perform Activities of Daily Living/Social Needs
ALF/SNF/Other Placement
Food Insecurity
Housing Insecurity
Medicaid/SNAP/Entitlement Program
Mental Health Resources/Support
Chronic Condition Management/Education
Non-Compliance with Treatment Plan
Long Range Planning/Decision Making
Establish In Home Support – Requires Supervision
Health Insurance Information
Arrangement of Transportation
Establish PCP/Specialist
Facilitate Discussion of Advanced Directives
Substance Abuse Resources/Support
Chronic Illness Present with NO Insurance or Access to Healthcare
Tutschek Fund
DME
NICU Patient