Région de Waterloo Wellington

Completed by a Coordinated Bed Access Coordinator (HCCSS staff) for transfers in the rehab bed program

Request for Hospice Palliative Care Services – Form 031B, Completed by a Primary Care Physician

Form 552, Notification of Rehabilitative Care, Palliative Care, Transitional Care or Residential Hospice Bed Vacancy

Formulaire de demande pour la divulgation de renseignements personnels. En vertu de la Loi de 2004 sur la protection des renseignements personnels sur la santé Veuillez

Fax cover sheet that can be used to accompany MAID referral document

Completed by a Primary Care Physician

To order care relating to parenteral therapy

Mental Health and Addictions Nursing Program Referral Form – Completed by a School Social Worker (SW) or Child/Youth Worker (CYW), Primary Care Physician, Psychiatrist, CAIP (GRH staff in the inpatient mental health program)

Can be completed by a Primary Care Physician, Nurse Practitioner, NSWOC(Nurse specializing in wound, ostomy and continence care), or CNS (clinical Nurse specialist)

Note: NPWT will continue to be assessed in the community, and settings may be reviewed based on exudate and patient tolerance. Continuation of NPWT is dependent on wound healing goals being met. Maximum treatment time for NPWT is 8 weeks.

FAX COMPLETED FORM TO Ontario Health atHome: 519-742-0635
How is Crisis defined?
A patient is considered to be “In Crisis” if:
1. Patient and/or caregiver safety is at risk and/or there is a risk that a significant health event and/or challenging end-of-life symptoms cannot be managed in their current setting
2. Patient at risk of requiring ED or acute care admission
3. Community resources have been exhausted and family/ caregivers are unable to cope with the patient’s care needs
4. There is a risk that the services required to meet the patient’s end-of-life care plan goals may not be available in their current setting
5. Patient at risk of not accessing their preferred place of death (considering recent trajectory of the PPS score).

Completed by a Primary Care Physician or Registered Dietician

Acute Care to Rehab & Complex Continuing Care (CCC) Referral

Request for Release of Personal Health Information under the Personal Health Information Protection Act, 2004

Completed by Primary care Physician to request Home Care services. Patient/Families may also print this referral form to bring to an appointment for completion.

Completed by Retirement Home(RH) or HCCSS staff to outline services that a patient is currently receiving or may require if moving to a Retirement Home setting

Completed by Retirement Home staff when requesting a Swallowing Assessment