Commander, Navy Installations Command
NAVY & MARINE CORPS
Fisher House Program
GUEST REFERRAL FORM
REFERRAL PROCEDURES
(A) Referral forms must be prepared and signed by a case manager, social worker, medical provider or military
liaison
(i.e. Recovery Care Coordinators, Wounded Warrior staff, Chaplains, CACO's etc.). They may not be
filled out as a self-referral.
(B) An advance referral form may be completed and submitted prior to the family’s arrival, but does not
guarantee availability.
(C) Families may not always be admitted on the first request. Admittance is based on Fisher House availability.
(D) One room is provided per family per referral and one parking space is provided per room.
(E) Referral forms must be sent directly via fax or email to the contact information provided above.
ADMITTANCE PROCESS AND GUIDELINES
(A) Families will be contacted by the Fisher House staff advising them of acceptance of the referral and an available
move-in date. Families may be admitted after the normal business hours of 8 a.m. to 4 p.m. if prior arrangements
have been made. Emergency or overnight walk-ins may be accommodated after contacting the House manager.
(B) Patients/outpatients are required to have a caregiver during their stay.
(C) General Fisher House rules and guidelines are covered at the time of check-in and guests are required to comply.
LODGING INFORMATION
Arrival Date: Estimated Departure Date:
Is guest on travel orders? Yes No No-Cost? Yes No
Guest is receiving reimbursement for the following (check all that apply): Travel Lodging Meals
GUEST INFORMATION
Name: Relationship to Patient:
1.
2.
3.
4.
Yes No
Email:
Home Phone: Cell:
Work Phone:
Vehicle License Plate:
Estimated Hospital Stay (# of days):
Will there be a service dog during this stay?
Home Address:
City:
State: Zip:
Vehicle Make/Model:
PATIENT INFORMATION
Name:
Location of Treatment::
In-patient: Yes No
A referral does not guarantee or reserve space in a Navy & Marine Corps Fisher House.
Naval Hospital Camp Pendleton Fisher House Office Hours:
Monday – Friday: 8:00 a.m. to 4:00 p.m. (closed on weekends and federal holidays)
Phone: (760) 763-5307 or 5308 / Fax: (760) 763-5309
Email: info@pendletonfisherhouse.org
Individuals receiving the following medical treatments are not eligible for admittance as a resident of the Fisher House:
home health nursing required; wound V.A.C. Therapy System units; Clostridium difficile (C-Diff.); Vancomycin-resistant
Enterococcus (VRE); total parenteral nutrition (TPN); running intravenous fluid drip (IVs).
SPONSOR INFORMATION
Name: Pay Grade:
Branch of Service: Navy Marine Corps Air Force Army Coast Guard
Status: Active Duty/Duty Station: Retired Military Veteran
HOSPITAL POINT OF CONTACT
Name of Person Filling Out Referral (Print):
Title/Department: Signature/Date
Phone: Email:
This authorization for release of the above information to the above named persons/organizations expires on:
I understand that:
(A) I have the right to revoke this authorization at any time. My revocation must be in writing and provided to the
facility where my medical records are kept or to the Fisher House manager if this is an authorization for
information possessed by the military treatment facility. I am aware that if I later revoke this authorization, the
person(s) I herein name will have used and/or disclosed my protected information on the basis of this
authorization.
(B) If I authorize my protected health information to be disclosed to someone who is not required to comply with
federal privacy protection regulations, then such information may be re-disclosed and would no longer be
protected.
(C) I have a right to inspect and receive a copy of my own protected health information to be used or disclosed, in
accordance with the requirements of the federal privacy protection regulations found in the Privacy Act and 45
CFR 164.524.
I request and authorize the named provider/treatment facility/TRICARE health plan to release the information described
above to the named individual/organization indicated.
The Fisher House accommodates families who need to be close to loved ones undergoing treatment as an inpatient at
any medical treatment facility.
The Fisher House is available for a period not to exceed 30 days to families who have no local accommodations. The
Fisher House serves as a compassionate and supportive home for families who are coping with the stress of a life-
threatening crisis. The Fisher House is not a step-down nursing medical facility and may not be treated as such.
PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of the purpose of the form
and how it will be used. Please read it carefully.
AUTHORITY: Public Law 104-191; E.O. 9397 (SSAN); DoD 6025.18-R: SORN DPR 40 DoD.
PRINCIPAL PURPOSE(s): The purpose of this form is to allow the DON (CNIC) Fisher House managers to determine
eligibility and priority for lodging at the Fisher House based on the criteria and eligibility as set forth in SECNAVINST
7010.8B.
ROUTINE USE(s): The routine use is to allow the DON (CNIC) Fisher House managers to determine continued eligibility
based on routinely updated medical status to allow for further lodging within the Fisher House.
This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical
records or for authorization to disclose information from records of an alcohol or drug abuse treatment program. In
addition, any use as an authorization to use or disclose psychotherapy notes may not be combined with another
authorization except one to use or disclose psychotherapy notes.
06/2022
