SilverStay Assisted Living referral

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Thank you for partnering with SilverStay. After submitting data on this form, SilverStay will immediately begin processing the referral, collecting more information from family if needed, and sharing de-identified information with Assisted Living communities to identify potential matches. We will provide you with updates via email using the designated patient ID.

Please note that privacy and encryption settings enforced by SilverStay ensure that information provided in this form remains private. We do NOT collect full patient names, dob, or other protected health information (PHI) through this form. Additionally we only share de-identified information with assisted living communities and NEVER share information that is indicated below as "(Private)."

Date *

YYYY

Hospital staff name (Private) *

Indicate the full name of the staff member at the hospital or SNF

Hospital staff contact number (Private) *

Indicate the contact number for the staff member at the hospital or SNF; Note: this information will be used by SilverStay to provide updates to hospital staff

Hospital staff contact email (Private) *

Indicate the contact email for the staff member at the hospital or SNF; Note: this information will be used by SilverStay to provide updates to hospital staff

How quickly does the patient need to be discharged? *

This information will be used by SilverStay Staff to determine the appropriate list of AL communities who may be able to take the patient.

URGENT: 4 - 12 hrs

24 hrs (1 day)

48 hrs (2 days)

72 hrs (3 days)

Other:

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