skip to content, health centers and clinics, search, accessibility statement

Contra Costa Health

Newsroom, About Us, Careers, Employees, Provider Information, Contact Us,

We have a new look!

Public Administrator

Referral Form

REFERRAL INSTRUCTIONS

STEP 1:
Complete the Online Referral Form (below) and click "Submit".

STEP 2:
Email all relevant documents supporting the referral to PublicAdministrator@cchealth.org or fax the documents to 925-646-1272.

Online Referral Form

Decedent's Name (First, Middle, Last):
Home Address:
City:	Zip:
Location of Keys to Residence:
Date of Birth:	Place of Birth:
Father's Name:	Mother's Name (include maiden name):
Date of Death:	Place of Death:
Social Security Number:	Marital Status:
Veteran: Yes No	Any papers from VA? DD214 Other:
Date Admitted to your facility:
Admitted From:
How did decedent arrive at facility:
Decedent's property held at facility:
Current Body Location:
Provide a brief history of events leading to referral:

NEXT-OF-KIN/FRIENDS/OTHER CONTACTS:
Name: Address:	Relationship: Telephone:
Name: Address:	Relationship: Telephone:
Name: Address:	Relationship: Telephone:
Name: Address:	Relationship: Telephone:

PROPERTY:
Real Property	Rent	Own
Address:
Landlord:		Telephone:
Vehicle:	Yes	No
Year:	Make:	Model:
Location of Keys to Vehicle:
Other personal property:

Documentation of Search for Next of Kin (specify who was contacted, when they were contacted, and what they said):

Referring Agency/Facility:
Completed By: Telephone: E-mail: (Copy of this online form will be sent to your e-mail)	Title: