• 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

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  • DIAGONISIS / MEDICAL CONDITION:

     

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  • SKILLED SERVICES / INTERVENTIONS: (Describe services the nurse or therapist will perform in the home, e.g. assess, teach, wound care, gait training.)

  • 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:

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  • 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.

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  • OPTIONAL PHYSICIAN DOCUMENTATION

  • This section is provided for the physician’s convenience and record keeping in the event of a Medicare audit.

  • 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.

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