Indigent Hospitalization Referral Form

Indigent Hospitalization Referral Form

Please utilize this HIPPA compliant platform to report ALL Indigent Psychiatric Hospitalizations

Client Name*

Legal Full First & Last only, do not include middle names or initials.

-

Client Preferred Name

Client Date of Birth*

Must be over 18 years of age.

Unhoused

Yes

No

Client Address*

Client Residence County*

Athens

Hocking

Vinton

*Other

*Other County*

Date of Request*

Pre-screener Completing Request*

Full Name

Pre-screener Email Address*

Psychiatric Admission Facility*

Columbus Springs East

Columbus Springs Dublin

Sun Behavioral Health

Ohio Hospital for Psychiatry

River Vista

Mount Carmel Behavioral Health

*Other

*Other Psychiatric Facility Information

Transportation Requested (Yes or No)*

Yes

No

Transportation Type Requested*

Indigent Status Confirmed?*

Yes

No, >24hr ER Wait / Involuntary Hold

*Other

*Other Indigent Status*

Number of Days Requested?*

3

5

7

Admission Date:*

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