DHS HCF Referral Form for Single Adult Shelter
The DHS HCF Referral Form is essential for healthcare facilities referring patients to the DHS Single Adult Shelter. This form determines the medical appropriateness of patients for shelter services. Proper completion ensures a smooth referral process for homeless individuals requiring assistance.
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How do I fill this out?
To fill out the DHS HCF Referral Form, start by gathering all necessary patient information. Make sure to check the eligibility criteria before completing the form. Submit the finalized form via email to the appropriate addresses listed in the instructions.

How to fill out the DHS HCF Referral Form for Single Adult Shelter?
1
Call the DHS Referral Line to confirm patient status.
2
Complete the form with accurate patient details.
3
Email the form to the designated email address for referrals.
4
Await a response from the DHS site or Office of the Medical Director.
5
Follow up if no response is received within the specified time.
Who needs the DHS HCF Referral Form for Single Adult Shelter?
1
Healthcare providers needing to refer patients to shelter services.
2
Social workers assisting homeless individuals with housing.
3
Long-term care facilities coordinating patient discharges.
4
Emergency shelters looking for additional support options.
5
Individuals seeking emergency housing assistance.
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What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, review your client’s needs throughout the year, ensuring timely submissions for referrals. Important months include January for new year resolutions on homeless outreach and September for plans before winter.

What is the purpose of this form?
The main purpose of the DHS HCF Referral Form is to facilitate the referral of homeless individuals from healthcare facilities to appropriate shelter services. It ensures that patients who require housing assistance are evaluated for their suitability based on medical and functional criteria. By completing this form, healthcare providers play an essential role in transitioning clients into the DHS system effectively.

Tell me about this form and its components and fields line-by-line.

- 1. Client Name: First and last name of the individual being referred.
- 2. DOB: Date of birth of the client.
- 3. Medical Appropriateness: Assessment of whether the patient meets the criteria for shelter placement.
- 4. Referring Healthcare Facility: The name of the healthcare provider submitting the referral.
- 5. Contact Information: Details of the person submitting the form, including email and phone number.
What happens if I fail to submit this form?
Failure to submit this form may delay the housing assistance process for the referred individual. It is crucial to ensure that all details are accurately filled to prevent issues with communication and placement into the DHS system.
- Delayed Housing Placement: Without submission, the patient could remain homeless longer than necessary.
- Miscommunication Risks: Incomplete forms may lead to misunderstandings between healthcare facilities and DHS.
- Potential Rejection: Improperly filled forms could result in denial of referral requests.
How do I know when to use this form?

- 1. Patient Transitioning from Hospital: Used during discharge to ensure the patient has shelter upon leaving.
- 2. Assessment of Housing Needs: Determines if the patient qualifies for single adult shelters.
- 3. Emergency Shelter Requests: Facilitates urgent placements for those facing homelessness.
Frequently Asked Questions
What is the purpose of the DHS HCF Referral Form?
This form is used to assess and refer patients from healthcare facilities to the DHS Single Adult Shelter.
How can I complete the form online?
Utilize our PDF editor to fill out the form digitally for ease of submission.
Where do I send the completed form?
Email the completed form to the appropriate addresses listed in the form instructions.
What if I need to correct information on the form?
You can easily edit the PDF in our editor before final submission.
Can this form be signed electronically?
Yes, you can add your signature directly to the PDF using our signing tool.
Is there a deadline for using this form?
Patients should be referred as soon as possible to ensure timely housing assistance.
What happens after I submit the form?
DHS will review the form and communicate determinations via email.
Can this form be used for patients with special needs?
Yes, the form allows providers to indicate specific patient needs that may affect placement.
How does the referral process work?
It involves confirming client status, completing the form, and awaiting a response from DHS.
What if I have more questions about the form?
Contact the DHS Referral Line for further assistance.
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