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

Has the woman being referred given birth?*
- Yes
- No
- Unsure
Please provide date of the baby's birth.
MM slash DD slash YYYY
Please provide anticipated due date.
Referrals for this program may be made once the prospective customer has entered her third trimester.
MM slash DD slash YYYY
Does the woman being referred live alone or alone with other minor children?*
Priority is given to new moms without supports in the home.
- Yes
- No
- Unsure

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.*

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