Get Direct Referral - Complex Care Program - Hamilton Health Sciences

This guide aims to provide clear and comprehensive instructions on completing the Direct Referral - Complex Care Program form for Hamilton Health Sciences. By following these steps, users can ensure that they provide all necessary information for a successful referral process.

Follow the steps to complete the referral form effectively.

1. Click the ‘Get Form’ button to acquire the Direct Referral - Complex Care Program form and access it in an online editor.
2. Begin with the Referring Source section. Select the appropriate hospital from the provided list, such as Hamilton General Hospital or MUMC/Chedoke McMaster.
3. Fill out the Referral Contact information. Include the name, email, and an alternate contact if necessary.
4. Specify the Program(s) Requested. Indicate either the Complex Continuing Care at St. Peter’s Hospital or St. Joseph’s Hospital, and provide the date and any other relevant information.
5. Enter patient’s personal information, including their last name, first name, address, telephone number, date of birth, preferred language, marital status, religion, and age.
6. Complete the Health Insurance Information section. Confirm whether the patient is covered under the Ontario Health Insurance Plan and provide their health card number.
7. Provide details for Next-of-Kin and Power of Attorney, including their relationship to the patient, address, and contact numbers.
8. In the Clinical Alerts section, include pertinent medical information such as allergies, diabetic status, and current infections.
9. Describe the patient’s current functional status in sections related to ambulation, bed mobility, and toileting. Be specific about dependencies and assistive devices used by the patient.
10. Outline any safety needs and the therapeutic surface requirements to ensure appropriate accommodations.
11. Provide any additional notes regarding the patient's special treatment, planning issues, or attachments required.
12. Finally, complete the section with the name and position of the person completing the referral, the date, agency, and their contact numbers. After filling out the form, make sure to save changes, download a copy, print, or share it as necessary.

Take the next step in the referral process by completing the Direct Referral form online today.