Intake Form

Visiting Rehab and Nursing Services/Home Again Healthcare

125 High Street, Suite 204

Mansfield, MA 02048

Phone: 877-242-8771

Fax: 774-244-4404

Patient Information

Patient Name*

First Name Last Name

Date of Birth*

Address*

Town*

Zip Code

Primary Number*

This is the first number to be called for scheduling purposes.

Phone

Who's phone is listed as primary?*

Note if this is the house phone. If it is not, please indicate their name and relationship to patient.

Secondary Phone

This is the second number to be called for scheduling purposes.

Phone

Who's phone is listed as secondary?

Note if this is the house phone. If it is not, please indicate their name and relationship to patient.

Type of home*

Select or enter value

Does patient reside with anyone?

Select or enter value

Provide name and relationship

Group home provider*

Group home manager/nurse manager name*

Group home phone*

Phone

List any known diagnoses

Insurance

Does Patient have Medicare/Medicare Advantage?*

Select or enter value

Medicare # or Medicare Advantage #

If patient has Medicare, please provide the Medicare number.

Medicare number should be in the following format:
1EG4-TE5-MK73
If it is not, you may have an old Medicare number.

If patient has a Medicare Advantage plan, please provide the Medicare Advantage number.

MassHealth #

Indicate NA if individual does not have MassHealth.

Other Insurance Name

Indicate NA if individual does not have other insurance.

Other Insurance #

Indicate NA if individual does not have other insurance.

Is this Individual part of the ABI MFP Waiver Program?*

ABI

MFP

Does this individual have waiver maintenance nursing needs?

Yes

Case manager/coordinator Name

Case manager/coordinator Phone

Case manager/coordinator Email

Primary Care Physician

Primary Care Physician Name*

First Name Last Name

Primary Care Physician Phone #*

Phone

Primary Care Physician Fax #

Primary Care Physician Address

Date of last appointment with this provider

Date of next appointment with this provider

Referral Source Information

Referral Source Name*

First Name Last Name

Referral Source Phone Number*

Phone

Referral Source Email*

Relationship to patient*

Organization Type and Name*

Please provide both organization type and the name of your organization.

Examples of Organization Type:

Adult Day Program
Assisted Living
Group Home
Skilled Nursing Facility
Hospital
PCP Office
Other

Does patient attend a day program?*

Select

What days and times do they attend?*

Day program Name*

Day program Phone Number*

Day program location

Provide full address if able to

Services Being Requested*

OT= Occupational Therapy

PT = Physical Therapy

ST = Speech Therapy

SN = Skilled Nursing

HHA = Home Health Aide

Equip= Equipment

Screen = Specialty Assessment/Screen

Select

Indicate Speech Area of Need

AAC = Augmentative and Alternative Communication

Select

Indicate Nursing Area of Need

Select

Nursing frequency need

If there is not a specific frequency of nursing needed please write NA.

Is patient currently at a hospital/nursing facility and being discharged?

If yes, please provide facility name and details in reason for referral section.

Select

Reason For Referral*

Please describe why patient needs services.

If this is a request for a specialty assessment/screen program please indicate which screens are being requested.

Adaptive Equipment
Fall
Environmental
Assistive Technology

Please Describe Equipment Needs

If none, please type "NA"

Has patient had a recent decline?*

Select or enter value

Please describe

Are they currently receiving any services?*

This includes nursing or therapy

Select

Name of agency and description of services

Guardian/Health Care Proxy

Patient's guardianship status:*

Please indicate if patient has a guardian, health care proxy (HCP) or is their own responsible party (ORP).

Select

Guardian/HCP Name*

Guardian/HCP Mailing Address*

Guardian/HCP Email*

Guardian/ HCP Phone*

Phone

Emergency Contact Name

Please indicate name and relationship to patient

Emergency Contact Phone

Phone

If you would like to receive a confirmation of your referral submission, please enter your email address below:

File Upload

If you have a face sheet, MD note or any other relevant information to add please upload.

How to upload using a mobile device:

Upload a document by taking a picture of the document with your mobile device or by uploading a document via "Attach a file."

How to upload using a computer:

Upload a document by choosing "browse files" or by dropping files into the designated area.

Drag and drop files here or

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