Va Form 10-0415 - Va Geriatrics And Extended Care (Gec) Referral Page 5

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This Section for Administrative Use Only
Use This Section Referral is processing (Check all that apply)
23. Where was the patient referred?
Funding Sources for
Funding Sources for
Home Care
Structured Living Situation
Structured Living Situation
Home Care
Community Skilled Home Health Care
VA
Personal Care Home
VA
VA Home-Based Primary Care
Medicare
Community Residential Care
Medicare
Homemaker/Home Health Aide
Medicaid
Assisted Living
Medicaid
VA Bowel and Bladder
Other insurance
Other insurance
Adult Day Health Care
Private Pay
Private Pay
Other (specify)
VA In-home Respite
Other (specify)
Funding Sources for
Funding Sources for
Domiciliary
Nursing Home Care
Domiciliary
Nursing Home Care
VA NHCU (Rehab)
VA Domiciliary
VA
VA
VA NHCU (Long-term care)
State Home Domiciliary
Medicare
Medicare
VA NHCU (subacute care)
Medicaid
Medicaid
Other insurance
VA NHCU (respite)
Other insurance
Private Pay
Community nursing home
Private Pay
Other (specify)
State Veterans nursing home
Other (specify)
VA NHCU (Hospice)
Funding Sources for
Funding Sources for
Geriatric Services
Hospice Care
Hospice Care
Geriatric Services
GEM Clinic
VA NHCU (Hospice)
VA
VA
Geriatric Primary Care Clinics
VA Outpatient hospice
Medicare
Medicare
VA GEM inpatient unit
Community hospice
Medicaid
Medicaid
Other insurance
Other insurance
Private Pay
Private Pay
Other (specify)
Other (specify)
Funding Sources for
Care Coordination/Home
Care
Funding Sources for
OTHER (specify)
Telehealth
Coordination/Home
OtherServices
Telehealth
Care Coordination/Home Telehealth
VA
VA
Medicare
Medicare
Medicaid
Medicaid
Other insurance
Other insurance
Private Pay
Private Pay
Other (specify)
Other (specify)
PATIENT'S LAST NAME, FIRST NAME, MIDDLE INTIAL
SOCIAL SECURITY NO.
Page 5 of 5
VA FORM
10-0415
MAY 2006

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