Recuperative Care Referral Form


For Los Angeles County and Orange County hospitals seeking to refer displaced patients to Horizon Recuperative Care, we invite you to download our Admissions Criteria and Referral Process Form.
Simply fill it out and email it to us at
You may also submit your referral using our digital form by clicking on our online referral form below.
Horizon response times are just a few hours, seven days a week. We’ll be in touch with you as soon as possible.


(323) 676-2000

    Medical Records: Admit H&P and Recent:

    Other Records:

    ADLs & Special Needs

    Independent with ADLs

    Recent Falls


    If Incontinent, can Change own Diaper

    Is Patient Ambulatory

    If not Ambulatory, Independent with Mobility

    Is Patient Competent

    History of Dementia or Alzheimer’s

    History of MRSA or Other Isolation

    History of Recent Substance Use

    Signs of Withdrawal

    Is Patient on Methadone

    If so, Enrolled in a Methadone Program

    Psych Diagnosis

    Is patient receiving psychiatric care

    Public Health Disclosure TB.

    All displaced persons are at risk for TB. Any displaced person with a new cough or change in cough for three weeks or with pulmonary symptoms suggestive of pneumonia.

    Must have CXR.

    There is a rise in the incidence of communicable diseases. In order to effectively manage client illnesses, CMIS requires that you report communicable diseases. This includes but is not limited to TB, VRE, MRSA, C-DIFF.

    If a patient has been identified to have scabies it is required that they have undergone treatment and have been cleared prior to admitting to the CMIS Program.

    Admission Criteria:

    1. Must have a primary medical problem
    2. Must be physically and psychiatrically stable to receive care in a medical respite setting
    3. Must be in need of short term recuperative care
    4. Must be able to participate in ADLs
    5. If on Methadone must be in a Methadone Program
    6. Must be mentally competent

    Exclusion Criteria:

    1. Incomplete treatment of Scabies
    2. Unable to transfer or perform ADLs
    3. C. diff / MRSA / TB
    4. Dementia/Memory Loss
    5. Combative/Violent behavior
    6. Hallucination/Delusion
    7. Psychiatrically Unstable
    8. Unable to self-represent
    9. Unable to perform ADL and transfer with assistance

    Face sheet, H&P, Meds, PT/OT, Social Service Evaluations, Current MD progress notes, Chest Xray or TB clearance