Referrals – Trinidad Recuperative Care

Phone

(949) 441-9833

Email

Location

Buena Park Ca,

Referral Application

Complete the Online Referral Form below.
Be ready to email us some pertinent patient information, including:

• Face Sheets
• Medical History & Physical
• Medication List
• Wound Care Notes
• Current Medical Progress notes
• Chest Xray or TB clearance
• Emergency Room Chart Notes
• Social Services Documents

Email referrals to [email protected]

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Referring Organization Name(Required) *

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Paying Hospital/Insurance Company *

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Referral Contact Name *

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Email *

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Phone *

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Date *

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Patients Contact Name *

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Date of Birth *

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Gender

Female

Male

Other

Referral Contact Name *

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Primary Language *

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MRN Number *

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Medical Reason for admission *

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Services *

Skilled Nursing Care
Assistance with Activities
Medication Management
Medical Monitoring
Rehabilitation Services
Memory Care

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Est. Length of stay at Trinidad Way *

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Is the patient currently medically and psychiatrically stable? *

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Is the patient in isolation for any communicable diseases? *

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I affirm that the above information is accurate to the best of my knowledge.

Yes

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Information

Phone

(949) 441-9833

Email

[email protected]

Location

Buena Park, Ca