Referral

Army Fisher Houses

Eligibility Requirements

A Patient must be a service member, retiree, veteran DoD civilian or their dependent.

Family must be traveling more than 40 miles one-way.

Referrals are NOT a reservation. Room availability is not guaranteed.

The Fisher House Manager is the approving authority for a stay at Fisher House. Placement is on a case-by-case basis.

Please contact the specific Fisher House for more information.

FOUO
Army Fisher Houses Referral Form

NOTE:  Select Location Prior to Completing the Referral Form

(SEE BELOW)

Select Location:

Referral completed by:

Phone#:

Date:

Patient Information

Name:

Diagnosis/treatment plan:

Doctor:

DOB:

On Orders?
AirEvac?
Campaign?

Ward?

Address/APO Address:

Email:

Branch:
Status:

Duty Phone:

Assigned to MTD? YesNo

Originating Unit:

Duty Station:

 

Guest Information

List everyone staying at the Army Fisher Houses. One room per family. Three people max occupancy (four if one is preschool or younger)

Names



Ages (if child)



Relationship to patient



Address:

Email:

Phone #’s

Home:

Cell:

 

 

Has anyone experienced a recent contagious illness? YesNo       If yes, what?

Does anyone have a military ID? YesNo

Vehicle Make and Model:

Will they have transportation while here?
YesNo
License Plate Number:

 

Any special needs or considerations?

Expected date and time of arrival:
Projected length of stay?

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