Send a Referral

01 About you

So we know who to call back with the answer.

Your name * Your role

Your relationship to them

Organization Phone * Email Best time to reach you

02 Who needs care

Fill in what you have. Blanks are fine — we will ask for the rest.

First name * Last name * Date of birth Client phone Home address (where care will be given) City * County ZIP Where are they right now?

Facility name and room Discharge date

Who do they live with? Preferred language Main contact — name Relationship to client Main contact — phone Second contact — name Relationship to client Second contact — phone Who signs the agreement? Does the client know about this referral?

03 Care needed

This is what tells us whether we can staff it, and how fast.

Services requested *

Requested start date * Hours per day Days per week

Schedule details Help needed with

Transfer assistance Memory and cognition Falls in last 6 months

Main diagnoses

Allergies Approximate weight Advance directive on file

Equipment in the home Infection or isolation precautions Conditions in the home Caregiver match preferences Anything a caregiver should know before the first visit

Physician name Physician phone

Is there a signed physician order or plan of care? Anyone else already involved Their agency name and contact

04 How care will be paid

If you do not know, choose "Not sure" and we will verify benefits.

Payer *

Level of benefits / claim type Claim number Date of injury Carrier, TPA or self-insured employer Adjuster name and phone Nurse case manager

Plan or carrier name Member or Medicaid ID Authorization number Authorized units or hours Authorization starts Authorization ends Bill to someone other than the client? Billing email

05 Send it

How did you hear about us? Anything else we should know

Referral summary — paste this into Curavil intake

01 About you

02 Who needs care

03 Care needed

04 How care will be paid

05 Send it

Here to work with us instead?