HOSPITAL PATIENT REFERRAL FORM

Refer A Family

GEMSI Senior Living Advisors | Rapid Discharge Support

Direct Intake Line: (951) 965-9330

Secure Email: referrals@gemsiadvisors.com

REFERRING HOSPITAL & CASE MANAGER

Hospital / Medical Center:

Unit / Floor / Room #:

Case Manager / Social Worker Name:

Direct Phone / Ext:

Case Manager Email:

Preferred Contact: ( Phone / Email )

Target Discharge Date:

Urgency Level:

PATIENT & DECISION-MAKER INFORMATION

Patient Legal Name:

DOB :

Gender:

Primary Language :

Legal Representative / Primary Contact Name:

Relationship to Patient:

Phone:

Legal Status:

Has Family Been Informed of Referral to GEMSI?

CLINICAL OVERVIEW & TARGET CARE LEVE

Recommended Placement Setting

RCFE Assisted Living (60+ years, physical ADL assistance, social setting)

RCFE Memory Care (Dementia / exit-seeking / requires locked perimeter)

RCFE 6-Bed Board & Care (High caregiver ratio 1:3, quiet residential home)

ARF Adult Residential Facility (Ages 18–59, psychiatric / behavioral / developmental profile)

Clinical & Mobility Profile

CDSS Ambulatory Status:

Transfers:

Cognitive Status:

CLINICAL OVERVIEW & TARGET CARE LEVE

Behavioral Needs:

Oxygen (Flow Rate: L/min)

Wound Care (Stage:)

Sliding-Scale Insulin

Incontinence (Bowel/Bladder)

Crushed Medications Order

Hospice Waiver Required

FINANCIAL & PAYOR STATUS

Estimated Monthly Budget for Placement: ($/ month)

Payor Source:

Medi-Cal Number (if ALW):

Share of Cost ($):

HOSPITAL AUTHORIZATION & ATTACHMENTS

Please attach the following clinical documents with this referral fax/email to expedite placement:

Face Sheet / Demographic Sheet

History & Physical (H&P)

Current Medication Administration Record (MAR)

Physician Progress Notes / Physical Therapy Notes

Case Manager / Social Worker Signature:

Date:

Refer A Family

GEMSI Senior Living Advisors | Rapid Discharge Support

SPEAK WITH AN ADVISOR

Call Us: 951.965.9330