EmailMeForm
PROFESSIONAL REFERRALS
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Logic
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Contact List
Please note that no need to forward or fax, these go directly to the clinician via email
HISC Staff Member making this referral:
Please select
Christian Steiner (Home Instead Senior Care, 212-614-8057)
Balbina Polanco (Home Instead Senior Care, 212-614-8054)
Francyne Felle, RN (Home Instead Senior Care, 212-614-8057))
Alberto Melendez, RN (Home Instead Senior Care, 212-614-8057))
Jessica Kallert (Home Instead Senior Care, 212-461-0570)
Francesca Cruz (Home Instead Senior Care, 212-614-8057)
Date referral made
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MM
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DD
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YYYY
Professional we are contacting:
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Please select
Manhattan House Calls (NP)
Hospice
Score PT (PT/OT)
Outreach PT (PT/OT)
Step Forward PT (Reshma D. Adwar) (PT/OT)
Dr Koslow (Podiatrist)
Dr Ciner (Podiatrist)
Dr. Teitelbaum (Podiatrist)
Dr Falcone (Podiatrist)
Optometrist - Dr Freed (SUNY)
Audiologist - Manhattan Audiology
Response Link
Fox Rehab (PT/OT)
PATIENT NAME
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DOB
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Address/ Phone #
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Medicare #
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PCP Contact Information (Name and phone #)
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Name of any Care Manager or Guardian involved (optional)
Add names and contact info only if applicable
Names of any other doctors/ professionals you need to be aware of
Check in the list of professionals and add anyone and their role that is of interest for this referral
Reason for referral
*
Ask CMS what to write in here
Diagnosis/ Medical History
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TAKE FROM CLEARCARE (ADL section)
Clinical Information
Go to CC
Go to Assessment
Choose (i) demographics (ii) Medications
Click Print
Save as PDF to your desktop
Then upload here
Patient Needs (choose the applicable one)
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Hospice Admission and services
Visiting NP Services - basic services (not looking to replace PCP) (Home Visits)
Visiting NP Services - basic services (they are looking for MHC to be PCP) (Home Visits)
Physical Therapy (Home Visits)
Psychiatric Nurse Evaluation and Visits (Home Visits)
Occupational Therapy (Home Visits)
Basic Podiatric Services (Home Visits)
Comprehensive Eye Exam (Patient's vision is impaired) (Home Visits)
Comprehensive Audiology Exam (Patient's hearing is impaired) (Home Visits)
Other
Please note that
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(*) The patient is NOT resistant to care
(*) The patient is resistant to care
(*) The patient is difficult
(*) Other, see below
Choose those that apply
After checking Medicare eligibility, please coordinate the first appointment
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Directly with me only via email
Directly with me only via phone (212-614-8057)
Directly with the Patient (and then please email me an update)
Other
Choose those that apply
Call
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Checklist below done!
1. Open the link
2. Call the professional
3. Tell them to please expect a referral form from us and
(a) let us know if they dont get it
(b) let us know if they can take the referral and provide the service
ADDITIONAL NOTES (optional)
Include mention that you are including photos etc
Any files to upload (discharge ppw, pictures of wounds etc etc) - optional