Online Referral Form

Re: RELEASE OF INFORMATION OF CHILD'S MEDICAL RECORDS

Greetings from Crescent Cove!

We are looking forward to getting to know your family in the upcoming weeks and months as we work through the enrollment process together. In order for us to secure a respite space for your child on our schedule, we will first need your permission to access his/her medical records.

Please complete and sign the appropriate release of information (ROI) documents if you have not done so already. These documents are valid for one year and will remain on file with Crescent Cove. Gillette Specialty Healthcare and Healtheast/Fairview require that we use their release of information form to access their medical records. All other health systems currently accept Crescent Cove’s ROI document or you can select the appropriate document from the links below. 

Medical records obtained by Crescent Cove will first be used to verify that your child meets our enrollment criteria at Crescent Cove. After enrollment criteria is verified, we will use the medical records to identify your child’s medical diagnoses, assist our clinical team in completing our admission orders and create a current care plan for your child’s stay. The types of records we are looking to obtain include a Homecare Plan of Care (485), POLST, current medication lists, recent Primary Care visits, consults from any Specialists, seizure protocol, asthma plan, autonomic protocol, and any additional information that you would find helpful for us to know about your child.

In addition, please complete the below list of current providers, so that we have your child’s up-to-date and accurate health information.

List of Current Providers

Once ROI forms are completed and signed, please return them to us via the fax or email address listed below. Our team will promptly send your child’s ROI’s to the assigned providers you have listed.  Once Crescent Cove receives your child’s medical records, we can confirm eligibility for enrollment with Crescent Cove, explore respite availability, and schedule upcoming respite visits for your child.

Please fill out one Authorization to Release Information form for each facility/organization that we will need to contact to access your child’s medical records.  

Allina

Crescent Cove

Children’s Minnesota

Children's Respiratory & Critical Care

Gillette Children’s

Fairview/HealthEast/University of Minnesota

Hennepin Healthcare

MN Gastroenterology

Noran Neurological

Pediatric Surgical Associates

Prairie Care

Please return all signed ROI’s to Admissions@CrescentCove.org or fax to 651.300.1350.

Sincerely,      

Your Team at Crescent Cove