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ADRC
ADRC

Professional Referrals

 

Please complete this form to make a professional referral to the ADRC of La Crosse County for a mutual customer. Please attach a completed authorization/release of information, if applicable, and if requesting a long-term care functional screen, please attach current problem/diagnosis list. If making a referral to the La Crosse County Senior Nutrition Program for home-delivered meals, please confirm that the customer lives in La Crosse County and is age 60 or older who is frail and unable to live their home due to illness, disability, or isolation. ADRC staff will confirm receipt of referral within 1-2 business days.

 

Has verbal/written consent been obtained for this referral?
D/C to SNF:
Referral to Elevate for MA?

CONTACT PERSON/LEGAL DESCISION MAKER (i.e., Legal Guardian, Activated POA) INFORMATION

Reason for Referral:

*If requesting a functional screen, please attach a full list of current diagnoses.

 

 

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