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Public Administrator

Referral Form


REFERRAL INSTRUCTIONS

STEP 1:
Complete the Contra Costa County Public Administrator Online Referral Form.

NOTE: The referent must demonstrate due diligence in locating next of kin. Diligent search examples include:

  • Review records for visitors, responsible parties, payees and friends and attempt to contact.
  • Review records from prior facility or placement. If none are available, attempt to get them.
  • Contact regular physician if admitting physician has not functioned as the primary care physician in the past.
  • Call any known payee, social worker, home health agency or therapist.
  • Review personal effects for possible relative references and attempt to contact.

Document all of your contacts on the referral form. Submit additional documentation if necessary. Reference who was contacted, when they were contacted and what they said. Be sure to include any documented statements by the decedent regarding relatives or lack thereof.

STEP 2:
Once completed, this Online Referral Form may be submitted by clicking "Submit" at the bottom of the page.

The referent must submit any relevant documents in support of the referral. Such documents may include: intake or admissions forms, inventory of personal items and/or contact list.

Online Referral Form

NEXT-OF-KIN/FRIENDS/OTHER CONTACTS:
PROPERTY:
Documentation of Search for Next of Kin (specify who was contacted, when they were contacted, and what they said):



Please email or fax any additional documentation (intake or admission forms, inventory of personal items and/or contact list) to:
Email: PublicAdministrator@hsd.cccounty.us
Fax: 925-646-1272