Waisman WIN: Wellness Inclusion Nursing Program University of – , Ste.100 Phone: (608) 265-9440 Fax: (608) 263-4681 Waisman WIN Referral Request Form Date: Individual’s Name: Last First M.I. Address: Street City Zip □ □ Telephone #: ( ) DOB: / / Age: Gender: Male Female Family Contact: Relationship to Individual: Phone: Cell: Email: Identifying Information SS #: M.A. #: Medicare #: Private Insurance Carrier: Subscriber I.D. #: Characteristic Code: Diagnostic Code: □ □ Dane Co. ACS#: CIP Waiver: Yes No Legal Information □ □ Power of Attorney (POA) for Healthcare: Yes No If yes, please forward copy of POA to this office. □ □ POA Activated: Yes No Date of activation: If yes, Name: Relationship: POA’s Phone: Email: □ □ Legal Guardian: Yes No If yes, Name: Guardian’s Relationship: Phone: Email: □ □ Living Will on File: Yes No If yes, please forward copy of the Living Will to this office. Service Information Support Broker: Phone: Email: Residential Provider: Phone: Email:
Waisman WIN: Wellness Inclusion Nursing Program University of – , Ste.100 Phone: (608) 265-9440 Fax: (608) 263-4681 Waisman WIN Referral Request Form Date: Individual’s Name: Last First M.I. Address: Street City Zip Telephone #: ( ) DOB: / / Age: Gender: □ Male □ Female Family Contact: Relationship to Individual: Phone: Cell: Email: Identifying Information SS #: M.A. #: Medicare #: Private Insurance Carrier: Subscriber I.D. #: Characteristic Code: Diagnostic Code: Dane Co. ACS#: CIP Waiver: □ Yes □ No Legal Information Power of Attorney (POA) for Healthcare: □ Yes □ No If yes, please forward copy of POA to this office. POA Activated: □ Yes □ No Date of activation: If yes, POA’s Name: Relationship: Phone: Email: Legal Guardian: □ Yes □ No If yes, Guardian’s Name: Relationship: Phone: Email: Living Will on File: □ Yes □ No If yes, please forward copy of the Living Will to this office. Service Information Support Broker: Phone: Email: Residential Provider: Phone: Email: