Palm Desert Referral Form

Contact

Address: 47250 Washington St, Ste B, La Quinta, CA, 92253

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Service Type (Select all that apply):
Disclaimer: If consumer has skilled tasks required, a separate skilled nursing authorization is required for those services.
Inland Regional Center Referral Form
Date Completed:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Consumer Information
Name:
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Language:
UCI#:
Address:
City:
Phone:
Format: (000) 000-0000.
Gender:
Do you have Military/Federal Affiliation?
Primary Insurance?
Family Contact Information
Name:
Phone:
Format: (000) 000-0000.
Relationship:
Language:
Social Rec Vendor Information
Vendor Name:
Phone:
Format: (000) 000-0000.
Email Address:
Referring Service Coordinator Information
Name:
Phone:
Format: (000) 000-0000.
Email Address:
EOR/PPS Respite Hours:
Agency Respite Hours:
Skilled Nursing Respite Hours:
FMS - Social Rec Hours:
Authorized Start Date:
Authorized End Date:
EOR Worker Information

(Complete ONLY if EOR Respite or EOR PA)
Name:
Phone Number:
Format: (000) 000-0000.
Email Address:
Relationship:
Language:
Please submit IPP and CDER, if available
Please submit IPP, CDER, and Medical History, if available
Upload Files:

Supported: pdf, doc, docx, xls, xlsx, csv.
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Please verify that you are human:
Skilled Nursing
palmdesertcahomecare-212@maxhealth.com
(760) 992-8582 Respite & PA Office
palmdesertcompanion@maxhealth.com
(760) 992-8581 FMS Contact
FresnoCAFMS@maxhealth.com
(559) 372-4145
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Inland Regional Center Referral Form