(Live) RAH Referral Form

Refer a Patient For Recovery at Home™

Thank you for choosing myLaurel™. We are honored to become part of your patient's care team.
Please enter the patient's zip code to determine coverage eligibility.*
We don’t currently service the area you entered. Please contact myLaurel at 866.603.7803 to speak with a myLaurel team member.
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Biological Sex Assigned at Birth*
Address*

Street Address

Street Address Line 2

City

Zip Code
State*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Patient Account Number (MRN)
Plan Name
Subscriber ID
Reason for Discharge / Chief Complaint*
Discharge Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Is the patient currently enrolled in a care management program?

Yes
Referring Person Information
Referring Person Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Referring Organization*
Email
example@example.com
Should be Empty:

Refer a Patient For Recovery at Home™