Referral Form - Cedar Hills Page 2
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1
2PRIMARYINSURANCE
SECONDARYINSURANCE
Carrier _____________________________________________________
Carrier ____________________________________________________
Subscriber Name ___________________________SS#_______________
Subscriber Name _____________________________SS#____________
Policy Number _______________________________________________
Policy Number ______________________________________________
Group Name _____________________ Group No. __________________
Group Name ______________________ Group No. ________________
Employer ____________________ Phone # ________________________
Employer ___________________ Phone # ________________________
OFFICE USE ONLY:
Closed Disposition
Referral Source/Professional Follow-Up
REFERRAL SOURCE FOLLOW-UP
Assessment Scheduled: : YES NO Date__________Time_______
Date _____________ Time______________ By ____________________
If No Assessment Scheduled, Reason _____________________________
Action Required ______________________________________________
Telephonic Referral Provided ___________________________________
Notes _______________________________________________________
Assessment Completed By: _____________________________
____________________________________________________________
Closed Disposition:
ACCEPT for ADMIT REFERRAL/NON-ADMIT
PATIENT/FAMILY FOLLOW-UP
Reason for Non-Admit _________________________________________
Date _____________ Time______________ By ____________________
Refer to _________________________ Agency ____________________
Action Required ______________________________________________
Admission
Notes _______________________________________________________
Date ________
Time ____________ Program ___________________
_____________________________________________________________
Physician Assigned __________________________________________
Additional Information:
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Parent category: Medical