Referral

Army Fisher Houses

The Army Fisher Houses provide a home away from home to families with a loved one receiving treatment at select military hospitals.
www.armyfisherhouses.org

REQUESTING A ROOM

Please complete this Referral Form. While not all information is required, it helps our staff to anticipate the level of support needed

Providers, case managers, chaplains, or other hospital staff should assist with completing and forwarding this form to the appropriate Fisher House for consideration.

Please note tat a referral to the Fisher House is NOT a reservation.

If approved, you will be provided additional information from the Fisher House where lodging is requested.

Due to our shared living environment, anyone with a potentially contagious illness or infectious condition is NOT appropriate to stay in the house.

Patients are not permitted to stay at the Fisher Houses alone, nor can we allow those with medical equipment attached for the collection of bodily fluids.

ARMY FISHER HOUSE REFERRAL FORM

For Official Use Only – Protected by the Privacy Act

    Select Location:

    FORM SUBMITTED BY

    Name:
    Phone#:
    Role:
    Date:

    Patient Information

    Name:
    DOB/Age:
    Status:
    Briefly describe circumstances:


    Hospital/Location:
    Treating Physician:
    Ward/dept/section where patient is being treated:

    FAMILY MEMBERS REQUESTING LODGING

    Note: maximum # allowable per family varies by location.

    Names (include age if under 18)




    Relationship to patient




    Phone #




    Address:
    Email:
    Do family members have military IDs?
    Is SM/family on orders?
    Will family have a vehicle here?
    Expected date of arrival?
    Projected length of stay?
    Are there any special considerations we need to be aware of?

    Military Sponsor's Information

    Name (if different from patient):
    Rank:
    Phone:

    Preferred Email:
    Unit & Duty Station:

    Unit POC:
    Status:
    Unit Phone:
    Branch:



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