Refer To Home Care

Date of Referral

Start of Care Date Requested

Referral Contact Person

Referral Contact Phone

Patient Demographic Information

Conditions Other Health

Last Name

First Name

Middle Initial

Date of Birth

Sex

Marital Status

Primary Phone

Phone Type

Email

Preferred Language

Communication Preference

Mobile Phone
Home Phone
Ok to Text

Lives With:

Address for Care

City

Apt/Unit

State

Zip Code

Special Instructions for Accessing Home

Entrance to use, animals, obstacles, etc.

EMERGENCY CONTACT INFORMATION

Contact Last Name

Contact First Name

Contact Number

Contact Email

Relationship to Patient

Patient Has Caregiver

Medicare Required Face-To-Face Requirement

Name of Ordering Physician

Physician/Office Phone

Physician/Office Fax

Physician Email

I am a Medicare PECOS enrolled physician, nurse practitioner, or
physician’s assistant and I certify that: This patient is confined
to the home and needs intermittent skilled nursing care, physical
therapy and/or speech therapy, and additionally may need occupational
therapy. The patient is under my care. A plan of care has been
established and will be reviewed periodically by a physician. A face-toface
encounter occurred no more than 90 days prior or 30 days after
the start of home health and was related to the primary reason the
patient requires home health services; the encounter was performed by
a physician or allowed non-physician practitioner on

I am a Medicaid enrolled physician, nurse practitioner, or
physician’s assistant and I certify that: This patient needs nursing
care, physical therapy and/or speech therapy and additionally may
need occupational therapy that is medically necessary.This patient is
under my care. A plan of care has been established and will be reviewed
periodically by a physician. A face-to face encounter occurred no more
than 90 days prior or 30 days after the start of home health and was
related to the primary reason the patient requires home health services;
the encounter was performed by a physician or allowed non-physician
practitioner on:

Medicare Date of Face-To-Face Encounter

Medicaid Date of Face-To-Face Encounter

Discharged in Past 14 Days?

Discharged From:

Transitions of Care Special Instructions

Equipment needed or ordered, special treatments, precautions, or other needs

Medicare and Medicaid Information

Medicare ID

Medicaid Number

#SS

Health Plan Information

Primary Health Plan Name

Health Plan ID

Group ID

Subscriber Name

Subscriber ID

Authorization Number

Secondary Insurance

Secondary Health Plan Name

Secondary Health Plan ID

Secondary Group ID

Secondary Subscriber ID

Clinical Information

Diagnosis 1

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

Diagnosis 6

Other Conditions or Complicating Factors

Services Requested

Additional Information & Documents

Additional Questions or Comments

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