Recuperative Care Referral Form

Fill out this form to refer an individual to the COTS Recuperative Care program. A member of the Recuperative Care team will reach out to you to discuss the referral within 48 hours via your preferred contact method. Please confirm you have the individual’s permission to refer them to the COTS Recuperative Care program before submitting this form. If the individual is experiencing a medical or psychiatric emergency, please wait to fill out this form and call 9-1-1. This referral form complies with HIPAA Privacy Policies. All information provided will be kept confidentially within the COTS Recuperative Care program and not used for any purposes other than determining eligibility for placement.

I am submitting a referral for... *

Myself
A family member or friend
My patient
My client

1) Basic Information about Individual being Referred

Name: *

First

Last

Date of Birth (DOB): *

Gender: *

Phone Number: *

Email: *

Communication Preference: *

Phone
Email

Individuals Current Location: *

2) Medical Information

Primary Diagnosis: *

Secondary Diagnosis: *

Current Medications: *

Reason for Referral: *

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? *

Yes
No
Unsure

e.g., COVID, MRSA, ETC.

Is the individual having uncontrollable seizures? *

Yes
No
Unsure

Is the individual able to co-exist in a communal environment with up to five roommates? *

Yes
No
Unsure

If incontinent, is the individual able to manage changing and cleaning themselves? *

Yes
No
Not incontinent

Is the individual diabetic? *

Yes
No
Unsure

Is the individual prone to falls? *

Yes
No
Unsure

Is the individual on Palliative Care? *

Additional Notes on Care Requirements: *

3) Activities of Daily Living (ADLs)

Bathing: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Dressing: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Toileting: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Transferring: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Eating: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

Taking Medications: *

Independent (I)
Needs Supervision (S)
Needs Assistance (A)
Dependent (D)

If you answered "Needs Assistance (A)" or "Dependent (D)" to any of the above, please explain. *

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) *

Please indicate which device(s) the individual requires to be mobile: *

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.

Insurance Member ID: *

Substance Use: Does the individual use alcohol or drugs recreationally? *

Yes
No
Unsure

Substance Use: is the individual interested in recovery/abstaining from substance use? *

Please describe the individual's behavior/mental health: *

e.g., Does the individual manage their mental health by taking medications as prescribed?

5) Primary Care Provider Information

Physicians Name: *

First

Last

Practice/Clinic Name: *

Physicians Phone Number: *

Date & Time of Next Appointment: *

Anything else COTS Recuperative Care staff needs to know when considering this referral? *

6) Referring Person's Information

Referring Persons Name: *

First

Last

Organization/Hospital: *

Relationship to the referred individual: *

Referring Persons Phone Number: *

Email: *

Your preferred contact method: *

Phone
Email
No Preference

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: *

True
False

an that contact

File Upload

Click or drag files to this area 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.

Recuperative Care Referral Form

Recuperative Care Referral Form

1) Basic Information about Individual being Referred

2) Medical Information

3) Activities of Daily Living (ADLs)

4) Social Factors

5) Primary Care Provider Information

6) Referring Person's Information

Locations

Contact

Mailing Address