Referral Line 24/7: 1-800-983-6242

Fax Line: 781-593-7169

Offices in Brighton, Lawrence, Lynn, Quincy View Locations

Make a Referral

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If you are a health care professional you may complete the following online form to make a referral. You may also download the form here and fax it to: 781-593-7169.





Your Name (required): Your Email (required):

Branch:

Site:

Choose One:  Admit Readmit Resumption

SOC/ROC:

Patient Information

Last Name: First Name:

Address: City: Zip:

Phone: Language spoken:

Date of Birth: (YYYY-MM-DD) Social Security #:

Emergency contact: Relationship:

Does Patient Live Alone? Yes No  Gender: Male Female 

Insurance Information

Primary: Policy #:

Secondary: Policy #:

Case Manager:

Phone #: Fax #:

Authorization #:

Authorization Dates (YYYY-MM-DD): To:

Insurance Verified:  Yes No

Initial: Date (YYYY-MM-DD):

Referral Information

Referral Source:

Admission Date (YYYY-MM-DD): Discharge Date (YYYY-MM-DD):

Person Referring: Phone: Fax:

Previous Inpatient Facility:

Admission Date (YYYY-MM-DD): Discharge Date (YYYY-MM-DD):

PCP: Confirmed:  Yes No Phone:

Pecos Enrolled:  Yes No

Surgeon/Other: Phone:

Confirmed:  Yes No Pecos Enrolled:  Yes No

Medicare Face-to-Face Encounter Form received from Referral Source?  Yes No

MD Follow Up Appointment Scheduled?  Yes No Appointment Date (YYYY-MM-DD):

Discharge Paperwork to be Faxed?  Yes No

Patient to be sent home with copy?  Yes No

Diagnosis Information

Primary DX:

ICD9 Code:

Secondary DX:

ICD9 Code:

Procedure DX:

ICD9 Code:

PMH:

Allergies:

Services Ordered

 SN PT OT SLP PSYCH MSW Assess for HHA

Specific Orders:

Other Pertinent Information

Assistive Device:

DME Vendor:

Vendor Phone:

Lab Draws:

Additional Information:

Referral Taken By:

Date ( YYYY-MM-DD): Time: