INTERIM BED REQUEST FORM

First Name:	Surname:
Address:
MOSAIC No.:	D.O.B:
Name of Allocated Worker: Role: LP:
Current Location (Please identify if this is a Hospital/ ILT discharge or Community case.)
Has Reablement been requested	Choose an item.
Referral type	Choose an item.
Does Section 117 aftercare apply?	Yes	☐	No	☐
Is this a request to extend a current interim bed?	Choose an item.
Original interim bed authorised by:
Dates:
Circumstances (short pen picture including evidence that if reablement was considered and is not appropriate, reasons for this and evidence that alternative options have been explored i.e. family support, telecare, wellbeing etc.)
Size of Care Package Required:	No. of Hours/Minutes
Date request sent to Brokerage:
Date package escalated:
Escalated by:	Choose an item.
Allocated Worker’s Recommendation:
Type of Interim Bed:	Choose an item.	Bed Cost:	Choose an item.
Additional Costs:	Choose an item.
Weekly Hours*:	*only complete where additional costs apply
Purchasing Team:	Budget Code:
Service Band:	Choose an item.
Is there a 3rd Party top up fee?	Choose an item.	Cost of 3rd Party top up fee:	Click here to enter text.
Who is paying the 3rd Party top up?	Click here to enter text.
Has 3rd Party agreement form been completed and uploaded to Mosaic?	Choose an item.
Out of County placement?	Choose an item.	If out of County, agreed with Commercial Team?	Choose an item.
Non-standard cost?	Choose an item.
Proposed provider and address of interim bed:
Room Number:
Start date required:	Proposed end date:
Transport Details:
Hospital Transport:
Lead Practitioner Signature:
Signed:	Date:
Authorising Manager Approval:
Signed:	Date: