Kunect Health || Home Page

1

Referral Source Information

Who is making this referral?

Referral Source Type *

Organization Name

Contact Person Name

Phone Number

Email Address

Fax Number

2

Patient Information

Details about the GAPP applicant

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Social Security Number

Phone Number *

Email Address

Address Information

Street Address *

City *

State *

ZIP Code *

Emergency Contact

Contact Name

Relationship

Phone Number

Insurance Information

Insurance Provider

Policy Number

Group Number

Medicaid Number

Medicare Number

3

Medical Information & Diagnosis

Patient's medical history and current conditions

Primary Diagnosis *

Secondary Diagnoses

Current Medications

Allergies

Medical History

Primary Care Physician Name

Physician Phone Number

Last Hospital Admission Date

Hospital Name

4

Skilled Nursing & Personal Care Needs

Types of care and assistance required

Skilled Nursing Needs (Check all that apply)

Wound Care

IV Therapy

Catheter Care

Medication Management

Vital Signs Monitoring

Diabetic Care/Insulin Administration

Ostomy Care

Tube Feeding/G-Tube Care

Personal Care Needs (Check all that apply)

Bathing/Showering

Dressing

Grooming

Toileting

Mobility Assistance

Meal Preparation

Feeding Assistance

Light Housekeeping

Special Equipment

Mobility Status

Cognitive Status

Requires Interpreter

Preferred Language

Frequency of Visits per Week

Additional Care Notes

5

Required Attachments

Upload supporting documents

Required Documents

Physician's order/prescription for home health services
Recent medical records or discharge summary
Insurance card (front and back) or Medicaid/Medicare card
Photo ID of patient
Power of Attorney or Healthcare Proxy (if applicable)

Upload Documents (Max 10 files, 10MB each)

Accepted formats: PDF, DOC, DOCX, JPG, PNG

6

Physician/Referral Signature

Certify the information provided

Signature Name *

Title/Credentials

License/Credential Number

Signature Date *

Authorization & Consent

Please read and accept the following authorizations to proceed with your referral application.

HIPAA Authorization *

I authorize Kunect Healthcare to obtain and use patient health information for the purpose of coordinating care and services.

Release of Information *

I authorize the release of medical information to Kunect Healthcare from physicians, hospitals, and other healthcare providers.

Patient Consent *

I consent to receive home healthcare services from Kunect Healthcare and understand the nature of services to be provided.

GAPP Referral Form

GAPP Referral Application