Request Free Senior Services | Mercy Care for the Adirondacks

Provider Referrals

If you are a Provider, Case Manager, Social Worker, or Health and/or Human Services Agency requesting services for a patient, client, or care receiver, click “Provider Referral” to download a fillable form. Once completed, please return to Mercy Care for the Adirondacks by email to kberger@adkmercy.org or by mail to Mercy Care for the Adirondacks, PO Box 7, Lake Placid, NY 12946.

For more information on Mercy Care’s Programs, Services, Volunteer Capacity, and the Referral and Intake Process, click “Referral Guide” to view and/or download our Referral Guide.

Provider Referral Form

Referral Guide

If you are referring a family member, a friend, or self-referring, please complete the form below to submit a referral to Mercy Care for the Adirondacks. If you would prefer to email or mail the completed form to Mercy Care, click “Referral Form” and download a copy. Once completed, please return to Mercy Care by email to kberger@adkmercy.org or by mail to Mercy Care for the Adirondacks, P.O. Box 7, Lake Placid, NY.

Referral Form

Date of Referral *

Prospective Elder/Care Receiver’s Contact Information

Date of Birth *

First Name *

Last Name *

Phone (Home)

Phone (Cell)

Email

Preferred Contact Method *

If other, please specify

Address (Physical) *

Mailing (if different from physical)

County *

Helpful Driving Directions

General Information

Languages Spoken *

Living Situation *

If other, please describe

Physical limitations and/or mobility barriers *

If other, please list mobility barriers

Are you currently on oxygen? *

Any communication/speech barriers, hearing or vision impairments *

If yes, please specify

Enrolled in Medicaid? *

How did you hear about Mercy Care for the Adirondacks

Referrer’s Information

Name *

Relation to prospective Elder *

Phone *

Email

Referrer’s Assessment (please complete even if a self-referral)

Reason for the referral (Provide a brief description of the need or challenges) *

Are there any health or safety concerns in the home? *

If yes, please describe

Have you or do you plan to refer to any other services *

If yes, please list

Services Requested (please check all that apply)

Friendship Volunteer Services

Friendly Home Visits

Friendly Phone Calls

Technology Assistance / iPad Program

Errands/Non-Medical Transportation

Medical Transportation**

Outings Together

Recreational Activities

Crafts, Gardening, Art, Music

Faith Community / Parish Nurse Services

Faith Community Nurses do not perform direct or hands-on health care, nor do they duplicate other nursing or medical services for the community.

Health Education and/or Personal Health Counseling

Connecting with Community Resources

Spiritual Caregiving

Advocacy

Spiritual Care Companion Volunteer Services

Spiritual Support (in-person or by phone)

Outings

Connecting with Faith Community

Health Care Companion Volunteer Services

Transportation to Medical/Health Appointments**

Accompaniment to appointments

Assistance with scheduling and/or follow-up

Medical/Health Forms

Navigating Health and Social Systems Portals

Errands (Prescriptions, other)

Permissions

Has the Elder agreed to this referral *

*May Mercy Care contact the Elder directly to set up an in-home Intake visit *

May Mercy Care contact the referral source *

*Intake Visit: To understand the elder’s needs and develop a mutual understanding of what the elder is requesting and what services Mercy Care is able to provide, elders must complete the referral process and have an in-home intake visit before they are eligible to enroll in Mercy Care services.

**Transportation Assistance Limitations: At this time, Mercy Care is unable to offer transportation assistance to those who use a wheelchair, cannot use a walker independently (i.e., Requires assistance getting up and/or sitting down), and are on oxygen. Additionally, because Medicaid provides medical transportation, we are unable to provide medical transportation to those enrolled in Medicaid. However, we can assist those enrolled in Medicaid with non-medical transportation.

To order, cancel, or inquire about Medicaid transportation services, contact Medical Answering Services (MAS) at 888-262-3975 or www.medanswering.com. Franklin and Essex County Medicaid Supervisor Contact for Medical Medicaid Transportation: 315-299-2758.

End of Referral: Please advise the prospective Elder that the next step in this process is for Mercy Care to review this referral. A Mercy Care representative will contact the prospective Elder. Please advise the prospective Elder to answer any calls from 518-523-5580.

For More information regarding Mercy Care’s referral and intake process please contact Mercy Care’s Director of Elder Care & Volunteer Services, at 518-523-5585.

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