Intake Referral Form

Intake Referral Form Template for Philippines

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Key Requirements PROMPT example:

"I need an Intake Referral Form for our mental health clinic in Manila, compliant with the Philippine Mental Health Act, with enhanced privacy protocols and specialized sections for psychological assessment documentation."

Document background

The Intake Referral Form is a crucial document in the Philippine healthcare system, designed to facilitate the seamless transfer of patients between healthcare providers and facilities. This document is primarily used when a patient requires specialized care, additional medical services, or transfer to another facility. The form captures essential patient information, medical history, reason for referral, and other relevant details in compliance with the Universal Health Care Act and Data Privacy Act of 2012. Healthcare providers must complete this form to ensure proper continuity of care and maintain accurate medical records. The Intake Referral Form serves as both a legal document and a clinical tool, enabling healthcare professionals to make informed decisions while protecting patient rights and maintaining confidentiality standards set by Philippine regulations.

Suggested Sections

1. Client Information: Basic demographic information including name, date of birth, contact details, and identification numbers

2. Emergency Contact: Details of primary and secondary emergency contacts

3. Current Health Status: Present medical conditions, symptoms, vital signs, and immediate health concerns

4. Medical History: Relevant past medical conditions, surgeries, and ongoing treatments

5. Current Medications: List of current medications, dosages, and known allergies

6. Reason for Referral: Primary cause for referral, urgency level, and specific services requested

7. Referring Provider Information: Details of the referring healthcare provider or facility

8. Insurance/Payment Information: Healthcare coverage details, PhilHealth information, and payment arrangements

9. Consent and Authorization: Patient consent for referral and information sharing, compliant with Data Privacy Act

10. Priority Classification: Assessment of referral urgency and required response timeframe

Optional Sections

1. Social Work Assessment: Additional section for cases requiring social services intervention or support

2. Mental Health Screening: For cases where mental health concerns are present or suspected

3. Disability Assessment: When patient has specific physical or mental disabilities requiring special attention

4. Cultural/Religious Considerations: Special cultural or religious requirements affecting care delivery

5. Transportation Needs: For patients requiring transportation assistance to referred facility

6. Language Assistance: When patient requires interpreter or language support services

7. Previous Referral History: Details of past referrals if patient has been previously referred

Suggested Schedules

1. Medical Records Release Form: Standard authorization form for release of medical records

2. Specialist Referral Requirements Checklist: Specific requirements for different types of specialist referrals

3. Required Medical Test Results: Copies or summaries of relevant medical test results

4. Medication List Template: Detailed template for listing current medications and dosages

5. Privacy Notice: Standard privacy notice in compliance with Data Privacy Act

6. Referral Network Directory: List of partner facilities and their specializations

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Social Services

Insurance

Mental Health

Public Health

Emergency Services

Rehabilitation Services

Elder Care

Disability Services

Primary Care

Relevant Teams

Admissions

Patient Care

Medical Records

Quality Assurance

Clinical Operations

Healthcare Administration

Social Services

Compliance

Patient Relations

Care Coordination

Relevant Roles

Medical Doctor

Nurse

Medical Administrator

Healthcare Coordinator

Social Worker

Medical Records Officer

Clinic Manager

Patient Care Coordinator

Healthcare Facility Director

Referral Specialist

Admissions Officer

Case Manager

Clinical Director

Quality Assurance Officer

Healthcare Compliance Officer

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Authors

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