Hospitality House Referral w/Letter of Medical Necessity

1135 S. Victor Ave, Tulsa, OK 74104

P: 918-794-0088 | F: 918-794-0631
Email: ekeena@hhtulsa.org

Referral Criteria

For Inpatient Families

Must reside 30 miles or further from Tulsa
Must be inpatient in one of the Tulsa area hospitals

For Outpatients

Must reside 50 miles or further from Tulsa
Must be accompanied at HHT by a full-time caregiver
Must be receiving outpatient treatment daily or at least 3 times per week

Patient Name *

First Name Middle Name Last Name

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	Country

Agency/Hospital Name *

Hospital Floor/Room # *

Requested Check In Date *

Date

Requested Check Out Date *

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 a Medicaid/Sooner Care member for either primary or secondary insurance? *

Yes No

Is the patient an infant in the NICU?

Yes No

Does the patient live 100+ miles from Tulsa?

Yes No

Date of Referral *

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 *

Date

Patient's Insurance Card

Browse Files

If available, please attach a copy of the patient's current insurance card

Agency/Hospital Information

Agency/Hospital Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Agency/Hospital Phone Number *

- Area Code Phone Number

Agency/Hospital Fax Number *

- Area Code Phone Number

Narrative/Justification

Confirmed Admit Date *

Date

Diagnosis Description *

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