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Thank you for making a referral to National Health Foundation's Recuperative Care Program.

Fill out the form below or if you prefer to make a referral over the phone you can call 888-NHF BEDS (888-643-2337) - 24 hours a day, 7 days a week. To send us more patient information you can fax us at 877-551-5580.

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.)

You can upload H&P notes, Face Sheet and Covid-19 test here or you can send them through fax at 877-551-5580.
Choose one or more files to upload, files must all be added at the same time or previous selections will be overridden.