NOTE: As we are a Sub-Acute Level of Care we generally do not admit patients requiring only care listed on this page as “Inclusive Care Services”.

This form is not required when sending a referral, however providing this form completed “ALONG WITH A REFERRAL” will help us respond with acceptance in a faster time frame!

Generally referred to as Level 1:

Patients are eligible regardless of the following: Age, Height, Weight or Sex.

List of services included in all the following listed levels of care:

  • Room and board & Twenty-four (24) hour nursing care
  • Meals & Preporation
  • Medication administration, oral, IM and subcutaneous (IV not included in this level) Routine Laboratory and radiology services
  • In and out cath care
  • New and existing ostomy care, training, and supplies
  • Medical/disposable supplies
  • Routine/standard DME (does not include bariatric, specialty mattress surfaces, bi-pap, c pap, wound vac., CPM, customized orthotics/prosthetics, customized wheelchairs) Oxygen and supplies
  • Amputee care
  • New and existing tube feedings, (gastrostomy, PEG) with nutritional supplements, and supplies.
  • Medically stable but requires health care needs to be assessed periodically 24 hours/day by licensed nurse or professional medical personnel
  • Medication administration (does not include antibiotics) and effectiveness
  • Restorative Nursing Care, Range of Motion
  • Skilled care reflects minimal nursing intervention / No rehab included in this level Co-morbidities do not complicate treatment plan
  • Discharge planning/Social Services/Case Management

CLHF Homes Patient Referral Form

  • MM slash DD slash YYYY

  • Level III Extensive Skilled Nursing Services:

  • Acute Care

    Level IV services include all prior listed services:

  • Please check off any of the below listed items IF PATIENT WILL REQUIRE:

  • PLEASE Do not forget to include the referral packet when sending this form over.

  • Max. file size: 50 MB.