Community Health Paramedicine Referral Form Referring AgencyAgency Name(Required)Type(Required)Agency Type Hospital Dr. Office Other Person Referring(Required)Phone(Required)Email(Required) Patient DemographicPatient's Name(Required)Gender(Required) Male Female Patient's Phone Number(Required)Patient's Date-of-Birth(Required) MM slash DD slash YYYY Patient's Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Patient Location(Required) Home Alone Home with Family Assisted Living Long Term Care Homeless Other Patient PCP(Required)Pt/Family aware and consent to referral?(Required) Yes No Admitting Diagnosis(Required)Discharge Diagnosis(Required)Short Term/Long Term Goals at Discharge(Required)Referral Reason (Check all that apply)(Required) Hospital/ER Discharge Follow-up Chronic Disease Mgt (HTN, Diabetes, Cardiovascular) Post Stroke/Stroke Risk Wellness Checks (VS, EKG's, Medication, Compliances) Specialty Services (PCP, PT, OT, Counseling Services, Home Health, Hospice) Social Services Consult (Food, Financial Assistance, Transportation, Housing) Mental Health Concerns Home Safety Assessment Fall Risk (>1 fall per month) If you have an immediate referral need, please call our office at 903-832-8531 to speak with our Community Health Paramedic staff.
