PHONE: 1.866.LHC.GROUP | FAX: 1.866.542.4768
RAPID REFERRAL FORM
PATIENT INFORMATION
Patient Name
Date of Birth
Zip Code
Contact Name
Contact Phone
Use x for Extension. Ex: 999-999-9999 x9999
Primary Diagnosis with ICD Codes Preferred
Comorbidities
Patient Insurance
REASON FOR REFERRAL(
Check Services Required
)
*
Wound Care/Negative Pressure Wound Therapy
Medication Management for
Disease Management Instruction for
Therapeutic Exercises
Other :
Was the patient in an inpatient facility within the last 14 days?
*
No
Yes
In my opinion it is medically contradicted for this patient to leave the home because the patient has:
Suspected or confirmed diagnosis of COVID-19
Patient has a condition that may make the patient more susceptible to contracting COVID-19
Authorization to use telehealth:
I authorize the use of telehealth and telecommunications as necessary and appropriate for this patient’s treatment
REFERRAL INFORMATION
Physician Name
Who should we contact in case we have additional questions about this referral?
Name
Phone Number
Use x for Extension. Ex: 999-999-9999 x9999
Email Address
Additional Information
FacilityID
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