REFERRAL FORM

All questions marked with a * below must be answered.
If you experience any problems submitting the form please call 406-216-8057 for assistance.

    RESERVATION DATES

    Please enter or select the requested arrival date. Submitting this referral is not a guarantee that we will have a room available on that date.

    Please enter or select the requested departure date. If you do not know the departure date please enter your best estimate.

    PATIENT DETAILS

    Enter Patient First Name

    Enter Patient Last Name

    Enter Birth Date

    Select gender

    Patient home / street address with Apt. number if applicable.

    In what hospital is the patient being treated?

    Enter attending physician's name.

    Please list any other information / comments here.

    REFERRAL AGENT

    Number must include area code.

    GUEST INFORMATION

    PLEASE NOTE: A maximum of 2 people (1 patient and 1 caregiver guest) are allowed per room at this time. Exceptions may be made but must be approved by the facility in advance.

    Number must include area code.

    PATIENT CONSENT DOCUMENTATION ON FILE

    It is required by HIPAA to obtain patient consent prior to transmitting any protected health information (PHI). You must check the box below to confirm that you have obtained the patient's consent to transmit the information on this form, and have documentation on file to support the patient's consent.

    In the event the patient is not able to provide consent, do not submit this form.