CABS Hospital And Clinic Referrals

This confidential form is being submitted on behalf of our Referral Partners

Referral Information

Referral Source
NYC H&H - Harlem HospitalOBH – Interfaith HospitalOBH – Kingsbrook HospitalOBH – Brookdale HospitalOBH – Pierre ToussaintMount Sinai Hospital
Date Submitted:

Submitted By:

Contact Email:

Contact Phone:

Department:
Select OneRehabCardiologyOncologyOB/GYNPsychiatryPierre Toussaint ClinicSocial WorkTransitional CareOther

Client's Personal Information

Client's First Name:

Client's Middle Name:

Client's Last Name:

Client's Date of Birth:

Client's SSN:

Client's Address:

Telephone(M):

Does potential client have an insurance plan?
YESNO

If not, does potential client need to be referred to an insurance plan?
YesNo

Does potential client need assistance applying for Medicaid?
YesNo

Medicaid CIN #

Name of Plan

Medicare

Name of Plan

Intended Service of Interest
Care ManagementHome AttendantHouse KeepingSkilled Nursing
Diagnosis 1:
Select OneDiabetesHypertensionAsthmaCongestive Heart FailureSickle Cell (Adult Only)Mental HealthDepressionSchizophreniaBi-Polar DisorderHIVOther
Diagnosis 2:
Select OneDiabetesHypertensionAsthmaCongestive Heart FailureSickle Cell (Adult Only)Mental HealthDepressionSchizophreniaBi-Polar DisorderHIVOther
Primary Needs:
Select OneBehavioral HealthHousingDMEPCPSpecialty medical centersOther
Is individual a veteran?
YesNo

Primary Doctor Information

Primary Doctor's Name

Primary Doctor's Number

Primary Doctor's NPI Number

Primary Doctor's Address

Emergency Contact

Emergency Contact Name:

Emergency Contact Telephone(M):

Relation to the emergency contact
Select OneSpouseParentChildFriend/NeighborCustodianOther
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Upon submission a member of our Intake Team will reach out and provide next steps. Thank you for your referral.

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