Refer a Patient | Vital Recuperative Care

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Referral submitted.

Thank you. Our intake nurse will review this referral and contact you within 24 hours. If the patient's discharge is imminent, please also call us at (612) 223-7691.

Referring provider

Contact information for the person submitting this referral

Provider / Referrer Name *

Organization / Hospital *

Phone Number *

Email Address *

Fax Number

Role / Title

UMPI / NPI Number

Social / Case Manager Name

Social / Case Manager Email

Patient information

Basic details about the patient being referred

Patient Full Name *

Date of Birth *

Gender

Patient Phone

Social Security Number

Client PMI (Patient Master Index)

Housing & insurance

Current situation and coverage

Current Housing Status *

Insurance Type *

Insurance / MA ID Number

Describe Client's Housing Situation *

Medical information

Clinical details to support placement review

Primary Diagnosis *

Primary ICD-10 Code *

Format: letter + 2 characters, optional decimal + up to 4 more (e.g. L89.154, E11.9, Z59.00).

Secondary ICD-10 Codes

Comma-separated. Include any comorbidities relevant to the recuperative-care stay.

Expected Discharge Date *

Admitting Hospital / Facility *

Admission Date

Attending Physician

Current Medications

Known Allergies

Medical Needs & Support Required

Additional Notes

Attachments

H&P, face sheet, progress notes, medication list, wound-care orders

You can upload up to 5 files, 20 MB each. Accepted formats: PDF, DOCX, JPG, PNG, TIF. If a file is larger or a secure-fax workflow is required, fax to (952) 400-3300 and reference the patient name you entered above.

Upload supporting documents

Click to choose files, or drag & drop here

PDF, DOCX, JPG, PNG, TIF · up to 5 files · 20 MB each

Notes on what you're attaching

Privacy notice

Please read and acknowledge before submitting

The information you provide is kept private. Information may be shared internally and with agencies involved in coordinating services for the client — only when necessary to determine eligibility or deliver care, and only with personnel whose roles require access, in compliance with applicable laws. The information you provide will be used solely to deliver the requested services or to assess eligibility.

Full Name — Privacy Notice Acknowledgement *

Release of information

Authorization to share information on behalf of the client

By signing this form, I give permission to Vital Recuperative Care to communicate with any agencies, organizations, property owners, landlords, contractors, individuals, or other relevant parties on behalf of the client. This authorization is intended to help the client receive recuperative care services. All shared information will be used solely to meet service-related needs.

Full Name — Release of Information Signature *

By submitting this form you confirm you have authorization to share this patient information.

Prefer to fax?

Fax supporting documents to (952) 400-3300 and call us to confirm receipt.

Call (612) 223-7691

Submit a patient referral.

Referral submitted.