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Fill out the form below. For questions, please call 213-514-6394 for LA County or 888-643-2337 for Ventura County.

Please attach clinicals, a face sheet and any other helpful documents to this referral (preferred). If you must fax or email the documents, you can do so to 877-551-5580 or intake@nhfca.org.

Please review our CRITERIA to make sure your referral is appropriate for our program. If you have questions, please call.

Referring Organization Information

If you are making a referral from the community or you don’t see your organization listed below, please select the guest’s assigned managed care plan under the Health Plan Source Type.

Referring Organization Source Type

Referral Source

Referral Source Contact

If you don’t see your information listed in our contacts, please add yourself below

Referral Source Phone #

Backup Referral Source Contact

Secondary Phone # (Office, Weekend, Nurses Station etc.)

Backup Referral Source Phone

Referral Source Email

Location

Referral

First Name

Middle Name

Last Name

DOB (MM/DD/YYYY)

Gender

Bed Gender Preference

Primary Language

Other Primary Language

Other Race/ Ethnic Background

Medical Reason for Admission

Managed Care Health Plan

If other health plan, please specify

Anticipated Hospital Discharge Date

Notes (Optional)

Criteria

Is the patient independent with ADLs, able to transfer themselves and able to ambulate a minimum of 100 ft?

Is patient continent of bowel and bladder? (OR are they able to independently manage using an adult diaper? No assistance available.)

Is the patient currently on any hold or isolation? We cannot accept with any isolations or holds, please send documentation showing clearance.

Does the patient have any open wounds?

If yes, please describe wounds (size/location/stage)

Please upload clinics, a face sheet, any specialty evaluations or relevant documents below (preferred) or you can send them through fax or email at 877.551.5580 or intake@nhfca.org.

Choose one or more files to upload, files must all be added at the same time or previous selections will be overridden.