Get Mn Regions Hospital Daybridge Referral Form

Completing the MN Regions Hospital DayBridge Referral Form online is an important step in ensuring proper care and treatment for individuals requiring mental health services. This guide provides clear, step-by-step instructions for filling out the form accurately and efficiently.

Follow the steps to fill out the DayBridge Referral Form online.

1. Click ‘Get Form’ button to access the DayBridge Referral Form and open it in your preferred editor.
2. Begin with the 'Referring Agency Information' section. Provide the name of the agency, clinic, or hospital, the specific inpatient unit if applicable, and contact details including phone number, discharge date, and the contact person responsible for the referral.
3. Continue to the 'Patient Information' section. Fill out the patient’s first and last name, date of birth, age, gender, race, marital status, social security number, language preference, housing status, and county of residence. Include the patient's living arrangement and home address with city, state, and zip code, along with home and alternate phone numbers.
4. Provide details for the outpatient psychiatrist. If there is none, clearly indicate that. Also include the primary care provider's information, the date of the patient's last physical examination, and the case manager's name, if applicable.
5. Fill in the insurance information, starting with primary insurance. Include the insurance company's name, phone number, ID number, and group number. If secondary insurance is available, provide the same details.
6. Move to the 'Diagnosis' section. Complete the diagnosis fields for Axis I, Axis II, and Axis III. Detail any current or recent chemical use, including the date of last use and any drug(s) of choice.
7. Indicate the status of the chemical dependency assessment and answer whether the client is currently or historically dangerous to themselves or others.
8. Explain the reason for referral to partial hospitalization, including the client's need and readiness for services. Report on the commitment status and confirm if the patient has a safe discharge plan in place.
9. Finally, make sure to attach any required documents such as history and physical reports, medication lists, current progress notes, MD discharge summaries, and commitment papers if applicable.
10. Review all entered information for accuracy. Once completed, you can save changes, download the form, print it, or share it as needed.

Complete the MN Regions Hospital DayBridge Referral Form online today to ensure timely and appropriate care.