ADMT Solutions Referral Form

REFERRAL FORM

This form is designed to capture initial referral information. It is not intended to be all inclusive. CMS or insurer may require additional information such as medical records from Physicians. Please keep supporting documentation such as d/c summary, labs, last office visit note and medication profile in your medical record.
Please complete this information and click the submit button below when complete. This form and its transmission certified HIPPA Compliant.
PATIENT INFORMATION
Referral Date: *

Month Day Year
Date
Name *

First Name Middle Name Last Name
SSN
Last four only.
Date of Birth *

Month Day Year
Sex *

Alternate Contact Name:
Alternate Contact's Number:

Area Code Phone Number
Relationship
Primary Care Physician: *
Physician's NPI #: *
Physician's Phone

Area Code Phone Number
Physician Email
example@example.com
Insurance Information:
Primary Pharmacy:
Office Contact Name: *
Office Contact's Number: *

Area Code Phone Number
Office Contact E-mail: *
Patient intake information will be sent to this email. Enter email recipient that meets HIPPA Compliance Standard.

DIAGONISIS / MEDICAL CONDITION:
(List the diagnosis / medical conditions that are the primary reason the patient requires home health care.) *
ICD-10 code (If Known)
ICD-10 code (If Known)
Last Flu Vaccine Date

Month Day Year
Date
HgbA1C Date:

Month Day Year
Date
HgbA1C Result:

SKILLED SERVICES / INTERVENTIONS: (Describe services the nurse or therapist will perform in the home, e.g. assess, teach, wound care, gait training.)
Skilled Nursing for:
Physical Therapy for:
Speech Therapy for:
Occupational Therapy for:
Social Work for:
Home Health Aide for:
ADDITIONAL ORDERS:

CERTIFICATION FOR FACE-TO-FACE ENCOUNTER
I certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me or a
physician who cared for the patient in an acute or post-acute facility had a face-to-face encounter related to the primary reason
the patient requires home health that meets CMS or insurer requirements with this patient on:
Face-to-Face Encounter Date *

Month Day Year
Date
Based on the above findings, I certify that this patient is confined to the home and needs intermittent skilled nursing, physical
therapy, and/or speech therapy. The patient is under my care and I have initiated the establishment of the plan of care for home
health.
Physician Signature: (sign with mouse or touch screen)

Clear
Signature Date: *

Month Day Year
Date

OPTIONAL PHYSICIAN DOCUMENTATION
This section is provided for the physician’s convenience and record keeping in the event of a Medicare audit.
CLINICAL FINDINGS: (Signs and symptoms of medical condition exhibited by the patient during the encounter that support the need for all services listed above.)
HOMEBOUND STATUS: (Describe the clinical and / or physical findings and the functional limitations that result in the patient’s normal inability to leave home.)
NOTICE: The attached communication contains privileged and confidential information. If you are not the intended recipient, DO NOT read, copy, or disseminate this communication. Non-intended recipients are hereby placed on notice that any unauthorized disclosure, duplication, distribution, or taking of any action in reliance on the contents of these materials is expressly prohibited. If you have received this communication in error, please destroy all pages and contact the sender or the ADMT Solutions Compliance Officer at 210-729-1252.
This form is HIPPA compliant and encrypted for the patients privacy.
Attach Insurance Information (If applicable)

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Attach Demographics Fact Sheet (If applicable)

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REFERRAL FORM