Patient Referral

Guidelines

Patients may be referred for non-emergency, outpatient & elective procedures.  Available services depend on availability of volunteer doctors.

In order to qualify, a patient must:
  • Not have health insurance or Worker’s Comp. coverage.
  • Be currently ineligible for any publicly sponsored insurance including Medi-Cal, Medicare, the Basic Health Care Program of Contra Costa Health Plan, or CMSP.
  • Earn less than 250% of the Federal Poverty Level: $29,700 for individual, $60,750 for family of four.
  • Not require ongoing care by specialist for successful recovery (referring clinic maintains responsibility for care after procedure and final appointment).

Clinic Contact Info
Referring Clinic Name *
Referring Provider
Primary care home (if different)
Phone *
Email *
Clinic Contact/Case Manager *
Phone *
Email *
Fax
Referral Date
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Patient Info
Patient First Name *
Patient Last Name *
Clinic ID # if any
Address *
Homeless *
If homeless provide case manager info
City *
State *
Zipcode *
Best Phone # *
Other Phone # *
Emergency Contact First Name *
Emergency Contact Last Name *
Contact Phone *
Language *
Ethnicity *
English speaker in household *
Date of Birth *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sex *
Biopsy requested *
If a malignancy is detected: the patient will be referred back to you (the medical home) for coordination of follow-up care. OA's scope of services is limited to the diagnostic procedure.
Surgical procedure requested *
Diagnosis/ Symptoms/ Relevant Treatment or Hospitalizations *
Visual Acuity and HbA1c (for eye referrals)
Body Mass Index *
Body Mass Index *
Previous Hospitalizations
Mental Illness *
Mental Illness Treated *
Current medications
Anticoagulants *
Allergies
Diabetes
If yes: Controlled? *
Previous Anesthesia *

If yes, any complications
Medications *
Co-Morbidities - existing and past conditions (yes or no):
Heart Disease *
Stroke *
Hypertension *
Lung Disease *
Kidney Disease *
Cancer *
Family History of Cancer *
Active Substance Abuse *
History of Substance Abuse *
Other
In one attachment include all relevant clinical information (check off what is included):
Progress notes (if relevant)
Most recent H&P/ Medical History
Imaging results
Labs
Pathology report
Surgical reports
Other
Upload relevant notes

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