Referral Form To Emergency Department PDF Details

In the intricate network of healthcare, the Referral To Emergency Department form stands as a crucial document, navigating the transition of care for patients from one medical setting to another. Located at 640 Jackson Street in St. Paul, Minnesota, the form is an essential tool for DayBridge, facilitating seamless communication between referring agencies, such as clinics or hospitals, and the emergency department. It captures a comprehensive snapshot of the patient's current medical and psychosocial status, including details such as the referring agency's information, patient demographics, medical and psychiatric diagnoses, current and past substance use, insurance details, and the specific reason for referral. Particularly noteworthy is the inclusion of details regarding the patient's safety risks to themselves or others and their readiness for partial hospitalization, underscoring the form's role in not just relaying medical facts but also ensuring the continuity and safety of patient care. Additionally, the exclusion of certain insurances by DayBridge underscores the complexities of healthcare coverage, making the referral process not just a medical decision but also a navigational challenge through the healthcare system's financial labyrinth. This form epitomizes the intersection of clinical need, care coordination, and administrative necessities in providing healthcare, highlighting the layered reality healthcare professionals navigate to ensure patients receive the appropriate level of care at the right time.

QuestionAnswer
Form NameReferral Form To Emergency Department
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesregions daybridge referral, TODAYS, applicable, Outpatient

Form Preview Example

DayBridge Referral Form

640 Jackson Street, St. Paul, MN 55101

Phone: 651-254-2402 Fax: 651-254-6655

TODAY’S DATE:

Referring Agency Information

Agency, Clinic, or Hospital:

Inpatient Unit:

Phone:

 

Fax:

 

Discharge Date:

 

 

 

Contact Person:

Phone:

Fax:

 

Pager:

 

 

 

 

 

Patient Information

 

 

 

 

First Name:

Last Name:

 

D.O.B.:

 

 

 

 

 

Please complete or attach documentation containing the following information:

Age:

Gender:

Race:

Marital Status:

SS #:

 

 

 

 

Language:

 

 

 

 

 

 

 

 

 

Housing Status:

 

 

 

 

 

County of Residence:

 

Living Arrangement:

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

 

 

 

Home Phone #:

City, State & Zip:

 

 

 

 

 

 

 

Alternate Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

Outpatient Psychiatrist Name:

 

 

 

 

 

 

 

Phone #:

 

If none, please indicate.

 

 

 

 

 

 

 

 

 

Primary Care Provider:

 

 

 

 

 

 

 

 

 

Date of last physical:

 

 

 

 

 

 

 

 

 

Case Manager Name:

 

 

 

 

 

 

 

Phone #:

 

If none, please indicate.

 

 

 

 

 

 

 

 

 

Primary Insurance:

 

ID #:

 

 

 

 

Group #:

 

 

 

 

 

 

 

 

 

 

 

 

Secondary Insurance:

 

ID #:

 

 

 

 

Group #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis

 

 

 

 

 

 

 

 

 

 

 

Axis I:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Axis II:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Axis III:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current or Recent Chemical Use:

___Use

___Abuse

___N/A

Date of Last Use:

 

 

 

 

 

 

 

 

 

Drug(s) of Choice:

 

 

 

 

 

 

 

 

 

CD Assessment Status: _____ Assessment needed

 

 

 

Assessment done

Referral made

 

 

N/A

 

 

 

 

 

 

 

 

 

Is Client Dangerous to Self or Others (currently or by history)? ____Yes ____No

Reason for Referral to Partial Hospitalization

Client need:

Client group Readiness:

Commitment Status:

Follow-up Appointments:

Does patient have safe discharge plan with support without inpatient hospitalization?

Please attach History and Physical or initial assessment, ROI, medications list, and current progress notes or MD discharge summary. *Attach commitment papers if applicable.

Insurance that we currently do NOT accept : Aetna, Ammerica’s PPO, Champ VA, MA pending, GAMC, Hennepin Health or Metropolotin Health, Humana, Select Care, UCARE, Value Options, WEA/WEIT, Wisconsin MA.

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Part # 1 of filling in DayBridge

2. Now that the previous segment is done, you'll want to add the necessary specifics in Housing Status Living Arrangement, Secondary Insurance, Home Phone Alternate Phone Phone, Phone, Group Group, and Diagnosis Axis I Axis II Axis III allowing you to progress further.

Writing section 2 of DayBridge

3. Completing Is Client Dangerous to Self or is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

DayBridge completion process clarified (stage 3)

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