Home · Custom Portal

Fill out the form below or if you prefer to call, please use 888-NHF BEDS (888-643-2337).

Please attach clinicals, a face sheet and any other helpful documents to this referral (preferred). If you can only fax those documents, you can do so at 877-551-5580.

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 Information

Referring Organization Source Type

Referral Source

Referral Source Contact

Referral Source Phone #

Location

Referral

First Name

Middle Name

Last Name

DOB (MM/DD/YYYY)

Gender

Bed Gender Preference

Primary Language

Other Primary Language

Other Race/ Ethnic Bacground

Medical Reason for Admission

Anticipated Hospital Discharge Date

Approved Length of stay at Recuperative Care Center (days minimum 15)

Notes (Optional)

Criteria

Is the patient ambulatory & able to transfer independently? (Walker, cane, or wheelchair is considered ambulatory)

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 medically and psychiatrically stable? (cleared from any transmission based precautions, etc.)

Please upload clinicals, a face sheet and other relevant documents below (preferred) or you can send them through fax at 877-551-5580.
If you have another phone number where we can reach you or someone else about this referral, please include them in the notes section above.

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