Nc Regional Referral Form PDF Details

Are you in need of a referral to one of North Carolinas's experienced healthcare professionals? It may seem overwhelming and confusing to determine who is the best fit for your individual needs. Fortunately, health departments across North Carolina provide access to an online Regional Referral Form which simplifies the process by connecting individuals with knowledgeable physicians specialized products, services and technology in their local areas. Keep reading as we share more about this convenient service so you can find the most appropriate medical rehabilitation or care that meets your personal requirements.

QuestionAnswer
Form NameNc Regional Referral Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesregional referral nc, adatc referral fillable, nc cdsa referral form, amazon

Form Preview Example

Facility Medical Record #:

 

Admitting State Hospital/ADATC: _________________________

Last 4 of SSN: __________

DATE: ___________________________ TIME: ______________

NC DIVISION OF MENTAL HEALTH/DEVELOPMENTAL DISABILITIES/SUBSTANCE ABUSE SERVICES

Regional Referral Form for Admission to a State Psychiatric Hospital or ADATC

Referral to: Referral made by:

Regional Psychiatric Hospital

Provider

LME

ADATC

Self-Referral

Other:____________________________

Name of Referral Source/Agency:_____________________________ Contact #:(____)_______________

Consumer/Patient’s Name:

 

 

 

_______

Date of Birth:

 

 

________________________

 

 

 

 

 

 

Last

First

Middle/Maiden

MM

DD

YY

Other Names Used by Consumer (if applicable): __________________________________________ Gender:

 

Male

Female

Legal Guardian/Parent Name:_____________________________ Relationship of Guardian to Consumer:__________________

Consumer/Parent/Guardian Address:______________________________________________ Phone :(

)________________

Consumer’s Ethnicity: _________________ Consumer’s Contact Number(s): Home :(

)____________ Work :(

)____________

 

 

Consumer’s County of Residence:____________________

 

 

Type of Admission:

Voluntary

Involuntary

 

 

Is Consumer Currently:

Suicidal

Homicidal

MI

SA

Describe (attempts, thoughts, plans):__________________________________________

MI/SA

 

_________________________________________________________________________

Mental Status (appearance/affect/behavior/hallucinations):____________________________________________________________

___________________________________________________________________________________________________________

Current Withdrawal Symptoms :_________________________________________________________________________________

___________________________________________________________________________________________________________

SUBSTANCE USE INFORMATION: PLEASE COMPLETE FOR ALL INDIVIDUALS SUSPECTED OF SA USAGE

Drug of Choice Priority #

Major Substances Used

Route *

Frequency**

Date Last Used

Average Amount Used

Form No. DMH 1-73-00 (Rev 12/07)

Page 1

*Route Codes: 1=Oral

2=Smoking

3=Inhalation

4=Injection

**Frequency Codes:

0=Drug not used during past month

 

1=Drug used 1-3 times in past month

 

2=Drug used

1-2 times in past week

5=Other 9=Unknown 3=Drug used 3-6 times per week 4=Drug used daily

ASAM PPC-2R CRITERIA: FOR USE WITH ADATC REFERRALS

Please select the appropriate level:

Level II – INTENSIVE OUTPATIENT / PARTIAL HOSPITILIZATION SERVICES

II.1 – Intensive Outpatient (more than 9 hours weekly)

II.5 – Partial Hospitalization (20 or more hours weekly) Level III – RESIDENTIAL / INPATIENT SERVICES

III.3 – Clinically-Managed, medium intensity Residential Treatment (Extended Care, therapeutic rehabilitation facility)

III.5 – Clinically-Managed, medium/high intensity Residential Treatment (Therapeutic Community, intensive structured treatment with ancillary services)

III.7 – Medically-Monitored Intensive Inpatient Treatment (ADATC – sub-acute, transitional services)

III.9 – Medically Supervised Detox/Crisis Stabilization (ADATC – acute care hospital. Up to level IV behaviorally and level III.7 or below medically)

**Lack of availability of appropriate, criteria-selected care and/or failure of a patient to progress at any given level of care may override the

patient-treatment match with regard to levels of service.

CONSUMER’S/PATIENT’S NAME:________________________________

FEMALE ADATC REFERRAL: CHECK ALL THAT APPLY

ADATC Perinatal Referrals Do Not Require LME Authorization

Individual is pregnant: Yes, # weeks _____ No Unknown If yes, include ALL prenatal care information

Individual has child(ren): Yes No If yes, Age(s)________________________________________________________

Form No. DMH 1-73-00 (Rev 12/07)

Page 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual has custody of child(ren): LastYesDosage:No If no, who

has custody:

 

 

Date of Last Dosage:

 

______________________________ Date of

 

 

 

 

 

 

 

 

 

 

 

Side Effects to Medications:

 

 

 

 

 

__________________________Date of Last Dosage: ____________

 

______________________________ Date of Last Dosage: ___________

 

 

Allergies: _______________________________________________________________________________________________

FEMALE WBJ-ADATC REFERRAL:

CHECK ALL THAT APPLY

 

 

 

 

 

 

 

______________________________ Date of Last Dosage: ___________

 

__________________________Date of Last Dosage: ____________

 

History of Compliance with Medications:

 

 

 

__________________________Date of Last Dosage: ____________

 

______________________________ Date of Last Dosage: ___________

 

Child under 1 year of age will accompany individual to WBJ

 

If yes, include ALL of child’s medical record

________________________________________________________________________

__ __ __ _

Date of Last Dosage:

__

___

_

_

_

_

_______Date of Last Dosage:

____________

Involvement by Department of DateSocialof LastServices:Dosage:__________________________

Yes_______

No

_________

 

_______Date of Last Dosage:

_

 

Time Vital Signs Taken:

BP:

Pulse:_________

Resp:_________ Temp:

Weight:_________

If yes, include DSS contact information (DSS caseworker name, agency name and phone number)

 

 

 

BAC: ____________ Time: ____________

 

 

 

 

 

 

 

 

 

 

_______________________________________________________________________________________________________

Labs Completed: _________________________________________________________________________________________

COMPLETE FOR ALL CONSUMERS/PATIENTS:

 

Fax applicable lab work along with referral form

 

Axis I:

 

 

Axis II:

 

Follow SB859 procedures for MR/DD referrals

Axis III:

 

 

Axis IV:__________________________________________________

 

Axis V: __________________________________________________

 

PCP Available:

Yes

No If Yes, Please Attach If PCP is not available attach current treatment plan and/or crisis plan

Previous Medical/Psychiatric/SA Admission(s) to Any Hospital/Facility in the past 3 months (where, when, why):

___________________________________________________________________________________________________________

Other Treatment Used Prior to Referral to Hospital: _________________________________________________________________

Reason(s) that Other Treatment Efforts were not Successful: __________________________________________________________

Medical History:

Heart Disease

Hypertension

Diabetes

Seizure Disorder

Pregnant

Ambulatory

Hepatitis

Chronic Pain

Recent Trauma

Recent Seizure

Asthma

Other ___________

Comments: _________________________________________________________________________________________________

Current Psychiatric Medications/Injections:

Current Medical Medications/Injections:

Pending Legal Charges:

Yes

No

Detainer (County)_____________________ Court Order

Yes

Unknown

Description:_____________________________ Court Order Attached

House Bill 95 (ITP)

Senate Bill 43 (NGRI)

 

No

Consumer Adjudicated Incompetent:

Is Consumer a Minor?

Yes

 

Yes

No If yes, attach copy of documentation if available

No

Name of Responsible Parent/Adult/Guardian:_________________________________

CONSUMER’S/PATIENT’S NAME:_________________________________

Goal of Hospitalization: _______________________________________________________________________________________

Treatment Objectives (Including specific suggestions for treatment planning):

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Proposed Discharge Plans: _____________________________________________________________________________________

Form No. DMH 1-73-00 (Rev 12/07)

Page 3

___________________________________________________________________________________________________________

Placement Considerations: _____________________________________________________________________________________

___________________________________________________________________________________________________________

Identified Additional Social Supports/Resources:

 

 

Name:

Address

Phone #

Relationship

____________________

_________________________________________

___________________________

______________

____________________

_________________________________________

___________________________

______________

____________________

_________________________________________

___________________________

______________

Additional Contact Information:

 

 

Clinical Home Provider Agency:_______________________________ Phone: (

)_______________ Fax: (

)_____________

Agency After Hours :________________________________________ Phone: (

)_______________ Fax: (

)_____________

LME Contact: _____________________________________________ Phone: (

)_______________ Fax: (

)_____________

(Hospital Liaison/Care Coordinator//Other LME Representative)

 

 

Assigned Psychiatrist:________________________________________ Phone: (

)_______________ Fax: (

)_____________

Community Support Provider:_________________________________ Phone: (

)_______________ Fax: (

)_____________

Other Provider: ____________________________________________ Phone: (

)_______________ Fax: (

)_____________

Third Party Coverage: Medicaid #: ____________________ Medicare #: ____________________ Other: ___________________

Insurance Co.: ____________________

Policy Holder: ____________________

Policy Number: ______________________

Attach copy of insurance card if available

If Insurance: Hospitals Contacted:

 

 

 

1)________________________________

Form completed by:__________________________________________

2) _______________________________

 

Signature

3)________________________________

__________________________________________ ______________

 

 

Title

 

Date

 

 

AUTHORIZATION BY THE LME: PRTF REFERRALS DO NOT REQUIRE AUTHORIZATION

Referring County:__________________ Phone#:_______________

 

 

Authorization #:__________________ From:__________ To*:__________

 

 

Hospital Beds

 

ADATC Bed

 

 

Adult Admissions

 

Acute

 

 

Adults Long-Term

 

Sub-Acute

 

 

Geriatric Admissions

 

 

 

 

Adolescent Admissions

* Day Not Covered

 

 

Child Admissions

 

 

 

 

Responsible County:_________________Phone #:_______________

 

 

Authorization #:__________________ From:__________ To*:__________

 

 

Hospital Beds

 

ADATC Bed

 

 

Adult Admissions

 

Acute

 

 

Adults Long-Term

 

Sub-Acute

 

 

Geriatric Admissions

 

 

 

 

Adolescents/Child Admissions

 

* Day Not Covered

 

 

Child Admissions

 

 

 

 

FOR STATE FACILITY USE ONLY – IF NO AUTHORIZATION INFORMATION IS PROVIDED BY THE LME: Referring County:__________________ Phone#:_______________

Hospital Staff Making Phone Call:___________________________

No Response Within 1 Hour of Call

If Response – Person Authorizing Days:_____________________

Responsible County:_________________Phone #:_______________

Hospital Staff Making Phone Call:____________________________

No Response Within 1 Hour of Call

If Response – Person Authorizing Days:______________________

PLEASE NOTE:

ANY MISSING INFORMATION MUST BE SENT TO THE ADMITTING FACILITY WITHIN ONE WORKING DAY OF

Form No. DMH 1-73-00 (Rev 12/07)

Page 4

THE CONSUMER’S ADMISSION. GUARDIANSHIP PAPERS MUST BE FORWARDED WITHIN ONE WORKING DAY OF ADMISSION.

Form No. DMH 1-73-00 (Rev 12/07)

Page 5

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