Hospitality House Referral w/Letter of Medical Necessity

1135 S. Victor Ave, Tulsa, OK 74104

P: 918-794-0088 | F: 918-794-0631
Medical Referral Form
Patient Name *

First Name Middle Name Last Name
Patient Diagnosis *
Guest Name *

First Name Last Name
Family's Phone Number *

Area Code Phone Number
Family's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Agency/Hospital Name *
Hospital Floor/Room # *
Requested Check In Date *

Month Day Year
Date
Requested Check Out Date *

Month Day Year
Date
Estimated Length of Stay *
Number of Days
Down Stairs Required? *

Yes No
Would the family like to use the Day Room? *

Yes No
Does the family have their own transportation? *

Yes No
Is the patient an infant in the NICU? *

Yes No
Is the patient a Medicaid/Sooner Care member for either primary or secondary insurance? *

Yes No
Is the hospital offering to provide meals for at least one parent? *

Yes No
Is at least one parent able to "room in" with the baby in the patient's current hospital room? *

Yes No
Is there a shower room available on the same floor as the patient that at least one parent can use? *

Yes No
Does the patient live 30+ miles from Tulsa?

Yes No
Date of Referral *

Month Day Year
Date
Case Worker/Social Worker Name *

First Name Last Name
Case Worker/Social Worker Email *
example@example.com
Case Worker/Social Worker Phone *

Area Code Phone Number
Letter of Medical Necessity

All medicaid patients are entitled to receive Non-Emergency Transportation services to include meals, lodging, and transport as mandated by federal regulation 42CFR440170. To be eligible to utilize these benefits, medical necessity of the patient's treatment at your facility must be documented to support the request. However, not all medicaid patients who apply will meet the state criterion set forth for approval. While mileage is not the only determining factory, typically patients are eligible for this benefit if they reside more than fifty (50) miles from the medical facility. DHHS Review Board will take into consideration ALL requests that are under the mileage criterion based on the circumstances from the narrative you provide below. All information in this document is confidential and must by handled in accordance with HIPAA regulations.
Patient Information
Insurance Provider *
Insurance Policy Number *
State *
Birthdate *

Month Day Year
Date
Patient's Insurance Card

Browse Files
If available, please attach a copy of the patient's current insurance card Cancel of
Agency/Hospital Information
Agency/Hospital Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Agency/Hospital Phone Number *

Area Code Phone Number
Agency/Hospital Fax Number *

Area Code Phone Number
Narrative/Justification
Confirmed Admit Date *

Month Day Year
Date
Gestational Age of NICU Patient at Birth *
Justification Narrative for Escort/Attendant *
Is it likely this recipient will be discharged to outpatient status for additional treatment before being discharged to home? *

Yes No
If yes, how many days will the patient by required to stay in the area prior to returning home after inpatient discharge?
Number of Days
I certify that it is necessary for this patient to receive treatment at the above facility and other requested services.
Staff Member Name/Title *
Signature of Staff Member (MD, RN, CNS, LPN) *

Clear
Should be Empty:

Medical Referral Form