Referral Intake Checklist

42 CFR 418.20 · 42 CFR 418.22 · 42 CFR 418.25 · Claims Manual Pub. 100-04, Ch. 11

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Educational Use Only

Referral Information

Patient Name:

Date of Birth:

MBI / HIC #:

Referring Provider:

Referral Date:

Referral Source:

Location / Facility:

Contact Number:

Primary Terminal Diagnosis:

Referring Clinician / Facility Contact:

Step 1 - Medicare Eligibility Screening

Confirm ALL items before scheduling a clinical evaluation. Do not dispatch a nurse until eligibility is established.

Patient is enrolled in Medicare Part A (not Part B only)Required for hospice benefit enrollment 42 CFR 418.20

Confirmed this is traditional Medicare fee-for-service (NOT Medicare Advantage)MA requires separate notification and has its own election process 42 CFR 418.20

Patient has a terminal illness with prognosis of 6 months or less if illness runs normal courseCertifying physician must make this determination - not intake staff 42 CFR 418.3; 418.22(b)(1)

Primary terminal diagnosis identified and documented in referral recordRequired to support certification narrative 42 CFR 418.22(b)(3)

Step 2 - Clinical Records Collection

History and physical (H&P) or recent physician note obtainedWithin 30 days preferred; most recent available if not

Discharge summary obtained (if recent hospitalization)

Most recent lab results relevant to terminal diagnosis obtained

Current medication list obtainedRequired for drug profile review at comprehensive assessment 42 CFR 418.54(b)(5)

Attending physician name and contact documentedPatient may retain attending; must be documented in election 42 CFR 418.24(b)(1)(ii)

Step 3 - Triage Classification (Select One)

ELIGIBLE - Proceed to clinical evaluation. Dispatch RN.

MEDICARE ADVANTAGE - Escalate per MA protocol. Do not process as traditional Medicare.

INSUFFICIENT INFO - Request additional records before dispatching clinician.

NOT ELIGIBLE - Document reason and communicate to referral source.

Classification notes:

Completed by:Date / Time:

Step 4 - Clinical Evaluation Handoff (If Eligible)

Clinical evaluation scheduled with RNInclude date, time, and location in handoff note

Clinical records transmitted to evaluating RN prior to visitRN should review prognosis documentation before evaluating 42 CFR 418.22(b)

Medical director notified of pending evaluation for admission recommendationMD must make admission recommendation before election 42 CFR 418.25

Family/caregiver contact verified and documentedCaregiver capacity assessed at evaluation

Referral source notified of evaluation timeline

Notes

Educational Use Only. Not legal advice. Verify against current primary sources and your organization's policies before use.