What the 21396 is for
The Connect Care Referral is a general AHS form for sending a consultation or e-Consult request to a service that uses Connect Care. Many AHS programs publish their own referral form and criteria in the Alberta Referral Directory, and those take priority. The 21396 covers the rest, with a consistent layout the receiving service can triage quickly. It is a referral, so it doesn’t replace any requisition the service needs for tests.
Who completes it
The referring provider completes it, or office staff complete it on their behalf. The Completed By block at the bottom asks for the name, signature, designation and date of whoever filled it in. The patient doesn’t complete any part.
How to fill in the referral
Patient and provider details
Enter the patient’s legal and preferred names, PHN or ULI, date of birth, administrative gender, address and phone. Fill in the referring provider, the family physician if different, and any legal guardian. The “Refer to” field names the service or consultant, so match it to the Alberta Referral Directory listing.
Referral Information
State the reason for referral as a clinical question the consultant can answer. Choose routine or urgent, consultation or e-Consult, and the patient’s current status. Use the comments for the details that justify the priority: the trend in symptoms, red flags, or results that changed. An urgent request with no supporting detail is often triaged as routine.
Current and Past Management
Say whether this is a new problem. If not, give the date of the previous referral, who it went to and the outcome. Note current or recent hospital admissions in the past two years. Attach or summarize past medical history, current medications and allergies.
Processing Requirements
Tick what you have included: blood work, diagnostic imaging, consultant letters, discharge summaries, microbiology or pathology. Many services list the investigations they need before they will book, so check the directory and attach the results.
Factors that may affect consultation or care
Note physical limitations, social or psychological factors, economic barriers, a preferred physician or location, and whether an interpreter is needed and in which language.
Common reasons it’s returned
- The service has its own referral form or criteria and the 21396 was used instead.
- No reason for referral, or one that doesn’t state the clinical question.
- Investigations the service requires are missing.
- No medication or allergy list.
- An outdated patient phone number, so the service can’t book the appointment.
Submitting and who pays
Send the referral to the receiving service by the method the Alberta Referral Directory lists for it. Referral is part of the insured visit, so there is no form fee to bill.