Sant Mary's Center

512 West 126^th Street	Phone: (212)665-5992
New York, NY 10027	Fax: (212) 665-5892 or (646) 619-6272

Adult Day Health Care Program Referral From

Name:	DOB
Address:	SS# Medicaid:
Phone #:

Date of HIV Diagnosis: Date of AIDS Diagnosis:

Viral Load: Date: CD4: Date:

Please attach a copy of latest lab reports (CD4, Viral load, Chemistry, Hematology & Lipid Panel), Immunization hx, and Proof of Status (positive antibody test or detectable viral load or M11Q)

HIV // AIDS Related Conditions: No Yes, list

Chronic Medical Conditions: No Yes, list

Allergies: NKA Yes, list:

Date of latest PPD: or N/A Results: Negative Positive

(within 6 months)

TB Status History or TB? No Yes, Treatment date & type

Latest Chest x-ray Date: Results:
(within 12 months) Please attach copy of Radiology Report

I am referring the above named patient to Saint Mary’s Adult Day Health Care Program who has a diagnosis of HIV AIDS. I believe that my patient will benefit from one or more of the services provided.
I am aware that certain medical information regarding the referred patient must be forwarded to Saint Mary’s Center within 30 days of this referral and that periodic updates of CD4, Viral Load and other aspects are required by the NYS DOH AIDS Institute.

Physician's Name: MD NP PA License #

Physician's Signature Date:

Address: Phone #: Fax #:

Please address all correspondence to: ext.

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