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Recuperative Care Referral

I am submitting a referral for...

1) Basic Information about Individual being Referred

Name:
Communication Preference:

2) Medical Information

Please describe the individual’s current physical/medical condition and why they need recuperative care services. Indicate the preferred date the individual would come to recuperative care:
Is the individual receiving rehabilitation services at a Skilled Nursing Facility (SNF) before coming to COTS Recuperative Care?
Is the individual oriented to date and time?
Is the individual able to make decisions independently?
Is the individual able to communicate their needs?
Is the individual free of communicable diseases?
e.g., COVID, MRSA, ETC.
Is the individual having uncontrollable seizures?
Is the individual hearing or vision impaired?
Is the individual able to co-exist in a communal environment with up to five roommates?
If incontinent, is the individual able to manage changing and cleaning themselves?
Is the individual diabetic?
Is the individual prone to falls?
Is the individual on Palliative Care?

3) Activities of Daily Living (ADLs)

Bathing:
Dressing:
Toileting:
Transferring:
Eating:
Taking Medications:
Is the individual able to ambulate up to 50 feet to the bathroom independently? (With or without an assistive device)
Is the individual able to ambulate up to 150 feet to the dining room independently using the elevator? (With or without an assistive device)
e.g., wheelchair, walker, cane, portable oxygen, none

4) Social Factors

Social factors do not necessarily determine the individual’s appropriateness for Recuperative Care services, but rather assist RC staff in understanding the individual’s needs and goals.
Housing Status
Insurance Type:
Substance Use: Does the individual use alcohol or drugs recreationally?
Substance Use: is the individual interested in recovery/abstaining from substance use?
e.g., Does the individual manage their mental health by taking medications as prescribed?

5) Primary Care Provider Information

Physicians Name:

6) Referring Person's Information

Referring Persons Name:
Your preferred contact method:
Consent: Did you obtain the individual's consent to make this referral to COTS Recuperative Care on their behalf?
I verify that the above information is true and correct based on my knowledge about the referred individual:
I verify that I have attached the following documents: History and Physical, Medication List, Physician's Report(s), Recent Lab Results, Detailing Diagnosis, Functional Assessment (physical limitations, mobility status, cognitive/ behavioral status, ADL assessment), and Support/Treatment Plan (Home Health, PT, OT, RN, wound care, dietary restrictions)
Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.
Please upload the referred individual’s most recent medical records here. This is recommended to expedite the process. Uploaded documents may be any combination of the following: History & Physical, face sheet, hospitalist progress notes, assessment plan, discharge summary, Physical Therapy or Occupational Therapy evaluations. At the very minimum, records should show the person’s diagnoses and medication list. Medical providers may also fax medical records to: (707) 776-4771. If you are not a medical provider, please submit this referral form without an attachment and an RC team member will contact you to discuss obtaining the medical records. The RC team must review the individual's medical records before accepting the referral.