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REFERRAL & REQUEST FOR SERVICES
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First Name of Member
Last Name of Member
Email
Address
County of Residence
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Phone
Birthday
Gender
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Insurance Coverage
Staywell LTC
Children Medical Services
Sunshine Health
Aetna LTC
Humana LTC
APD Waiver
Allergies (Alergias)
Nutritional Requirements or Special Diet (Requerimientos Nutricionales o Dieta Especial)
Medical Equipment or Supplies used by the Member ( cualquier equipo médico o suministros utilizados por el miembro)
Medications (name/dose/route/frequency)- Medicamentos (nombre/ dosis/rute/frequencia)
School Attending (Name/start time and end time)- Escuela en que Atende (nombre/hora de inicio y hora de finalización)
Member's Diagnosis-Diagnóstico del miembro
Is Assistance needed in school? (School Letter Required) -¿Se necesita asistencia en la escuela? (Carta de la escuela requerida)
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Single Parent Home? -¿Hogar monoparental ?
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If there are other Children in the home - Please include ages and if special needs, include thier diagnosis-Si hay otros niños en el hogar, incluya edades y, si tiene necesidades especiales, incluya su diagnóstico.
Other Children in the Home?-¿Otros niños en el hogar?
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Case Manager Information (name, email, phone); Case Notes; Diagnosis
Do the other children have special needs?-¿Los otros niños tienen necesidades especiales?
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