If you are calling to make a referral, please be prepared to provide the following information:

*No admissions if patient has Medicaid and is between 21 years old and 64 years old.
*Susan Lake must be beeped for all HIP, IHS, Dept. of Corrections and NYPD referrals.
*Medicare referrals must wait until the morning to be verified
*After-hour referrals must be approved by Susan Lake.


Person Calling in Referral:     
(Name and Telephone Number)

Calling From:   
(Agency)

Patient's Name:                                                      

Address: 

Phone:     
   
Date of Birth: 

Next of Kin:
(Name and Phone Number)

Insurance Company:

Insurance Company Phone No.: 

Employer, Policyholder Name, Date of Birth, Social Security No.: 

Any prior hospitalizations, current year: 

Reason for Hospitalization:  

Medical Diagnoses (if any) 
 
Medications: