Referral Program – LifeCare Alliance

This application is secure. All submitted information is secured with bank-level encryption to ensure privacy and compliance with federal HIPAA regulations. By completing this referral application, you attest that you are either the client or are authorized by the client to submit personal/protected information to LifeCare Alliance on their behalf. Information collected in this referral application will become part of the client’s file at LifeCare Alliance.
What is the source of this referral*
- Referring Agency
- Physician's Office
- Self
- Family
- LifeCare Alliance (Staff Use Only)
LifeCare Alliance Employee Name*
Your Email Address*

Patient Information
Name*
First Last
Date of Birth
MM slash DD slash YYYY
Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
County of Residence
Emergency Contact
First Last
Emergency Contact Relationship
Emergency Contact Phone

Insurance Information
Does the patient have medical insurance?
- Yes
- No
- Unknown
Primary Insurance Carrier
Primary Insurance Member ID
Primary Insurance Group #
Does the patient have secondary medical insurance?
- Yes
- No
- Unknown
Secondary Insurance Carrier
Secondary Insurance Member ID
Secondary Insurance Group #

Demographics
Race*
Gender*
Household Size*
Ages of Household Member(s)*
Please list the age of each household member. Please do not include household member names.
Requested Services
Meal Type*
- 10 Frozen Meals (home-style frozen meals in 3-compartment trays)
- 2 Carrie’s Café Cold Meals (deli-style boxed lunches)
Number of 10-packs of frozen meals requested per week*
Limited to the number of individuals in the household, and to your available storage space.
Number of weeks you would like to receive the meals*
Subject to funding availability.
Please enter a number from 1 to 10.
Number of 2-packs of Carrie's Café cold meals requested per week*
Limited to the number of individuals in the household, and to your available storage space.
Number of weeks you would like to receive the meals*
Subject to funding availability.
Please enter a number from 1 to 10.
Pickup Day*
All frozen and cold meals will be available for pickup at Carrie’s Café, 670 Harmon Ave., 43223 between 11:00AM and 1:00PM.
Disclaimer
Release of Information*
LifeCare Alliance’s funding sources and community partners monitor the effectiveness of programs offered to its consumers. Therefore, it may be necessary for LifeCare Alliance to provide written or verbal health related and financial information for the purpose of providing and coordinating services received from the Agency. All information will be kept confidential and no personal identifying information will be released to the public without written consent, unless required under Federal law. Although all persons receiving services are asked to provide this information, no person may be denied services for refusing to provide any of the requested information. By submitting this completed online referral form to LifeCare Alliance, I agree that I have read the Release of Information statement and understand that my submitted information may be reported, as needed, to LifeCare Alliance’s funding sources and community partners.
- I agree

Diabetic Counseling
Please Choose from the Services Below:
- Individual counseling (in-home or office consulation)
- Group counseling/classes
- Both
- I don't know
Diabetes Diagnosis Code*
A1C*

Columbus Cancer Clinic
Free or Low-Cost Cancer Screenings and Mammograms*
- Mammograms, breast ultrasounds & breast biopsies
- Pap tests and pelvic exams
- Colon cancer screening tests
- Prostate cancer screening tests
- Skin cancer screening tests
When was the patient's last mammogram?*
Where was the patient's last mammogram performed?*
Are there any signs or symptoms such as a breast lump, nipple discharge or retraction, or breast dimpling?*
Please fax an order with diagnosis code to 614-263-5019.
Primary Care Provider Name
First Last
Primary Care Provider Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Care Provider Phone
Are Interpreter Services Needed?*
- Yes
- No
- Unknown
Language Needed*

Referring Physician Information
Practice Name*
Phone*
Fax*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
PCP/Referring Physician Name*
NPI #*
Medicare #*

Referring Agency Information
Name of Referring Agency*
Name of Agency Representative Making Referral*
Relationship to Patient*
Agency/Representative Phone*
Agency/Representative Email*
I have communicated the service basics and referral process for the identified LifeCare Alliance services to the person being referred.*
- Yes
- No
The patient referenced on this form agrees to proceed with the assessment process for the identified service(s).*
- Yes
- No
If you answered no above, provide background information so that we may proceed with initiating service.*

Family Referral Information
Name of Person Submitting this Form*
First Last
Relationship to Client*

Submit
How Did You Hear of LifeCare Alliance?
Your referral submission is almost complete. Please follow any instructions in the reCAPTCHA field below, then click Submit. If you have any questions or concerns about this process, please contact our Customer Service Department at 614-278-3130.

By submitting this form, I hereby consent to the disclosure of the records to the purpose and extent stated. This authorization may be revoked by the client at any time to the extent that disclosure has not already occurred prior to the request for revocation. I understand that in order to revoke this authorization I must do so in writing. I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure by the person or entity receiving such information.
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Refer to LifeCare Alliance

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Columbus Cancer Clinic

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Referring Physician Information

Referring Agency Information

Family Referral Information

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