Care Chexx Referral Form

Required For All Admissions

Questions: 612-541-8808

Referring Agency Information

Requesting Agency

Person Making Request

Your Job Title

Phone Number

Unit Phone Number (Optional)

Mobile Number

Your Email Contact

Client's Medical Assistance Number

Client's Insurance Service Provider

Insurance Provider's Client ID (If Different)

Client's EHR ID Number

Client's First Name

Middle Name

Last Name

Suffix

Social Security

DOB:

Race

Gender

Client's Phone Number

Expected Discharge Date

Preferred Language

Religious Preference

Emergency Contact Person

Emergency Contact's Number

Reason For Referral Request

Medical Diagnosis Code #1

Diagnosis Code #2

Diagnosis Code #3

Upload Client Discharge Documents (Preferred) or Fax Face Sheet to 763-205-5108

Transportation Needs

Anticipated Length of Stay Needs

Referral Submission Declaration

By submitting this referral request to Care Chexx Recuperative Care Services, I affirm that all information provided in this form is complete, accurate, and truthful to the best of my knowledge. I understand that any omission or misrepresentation of relevant details may affect the evaluation and outcome of this referral. To be eligible for recuperative care services, an MHCP member must meet all the following criteria. 21 years or older if they have Medical Assistance, or 19 years or older if they have MinnesotaCare. Experiencing homelessness or are unhoused. In need of short-term medical care for fewer than 60 days. In need of assistance with recuperative care covered services. Client is ambulatory and able to toilet and shower independently.

Care Chexx Referral Form

Required For All Admissions

Referring Agency Information

Your Preferred Recuperative Care Provider