HH - Referral

1. Patient Name*
First and Last Name
3. Patient Phone*
Please enter a valid phone number.Format: (000) 000-0000.
4. Insurance Information*
Provider Name and Policy Number
5. Primary Physician*
6. Date of Last Doctor Visit

MonthDayYear
Date
YesNo
If yes, who is the Physician?
Appt time/date

MonthDayYear
Date
Hour MinutesAM/PM Option
8. Identify any caregivers in the home or family support. Name and phone number of caregiver?
9. To be eligible for Medicare home health services a patient must have Medicare Part A and/or Part B per Section1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act (the Act):
- Be confined to the home;
- Need skilled services;
- Be under the care of a physician;
- Receive services under a plan of care established and reviewed by a physician; and
- Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP).
YesNo
Institution Questions:
10. How many times has this patient been in facility in the last 60 days? How many days were they in the facility?
11. Is this patient being admitted for observation or full admit?
12. Has this patient been to an ER in the last 30 days? If so, when and for what duration?
File Upload: Upload any relevant patient documents here, including: Face sheet, medication list, face-to-face encounter, admission order, medical records. (Documents are not required to complete referral but are required to complete admission.)

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