Covenant Health Services Inc referral form

Client Referral Form

Thank you for choosing to refer your patient to Covenant Health Services Inc. To start the referral process, please fill out this form and fax it to our office, or you can visit us at our website!
Patient Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Social Security
Patient Medicaid Number:
Patient Medicare Number
Guardian/Legal Representative (If applicable)
Name: Phone: ( ) Area Code Phone Number

REASON FOR REFERRAL

(please circle all applicable)
Patient’s Diagnoses:
Reason for home Care Services:*

Skilled NursingMedication ManagementPhysical TherapyOccupational TherapyHome Health Aide
Physician Name:
NPI Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone

Area CodePhone Number
Fax
Physician Signature*

Clear
Date

MonthDayYear
Date

Face to Face Encounter Verification
I had a face to face encounter with*
On this date*

MonthDayYear
Date
(In order to be reimbursed for home health care services, all Medicare patient are required to have a documented face to face encounter with an eligible health care provider within 90 days before or 30 days after the initiation of needed home health care services.)
The following services are medically necessary home health care services:

Skilled NursingPhysical TherapySpeech TherapyOccupational Therapy
Certification of Homebound Status:
My clinical findings from this encounter support the patient is homebound due to:

Leaving home requires a considerable and taxing effortAbsences from home are infrequent, of short duration or to receive healthcare treatmentMedically restricted due to immunosuppression, infectious illness, risk of infection or injury,Other
Physician Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Client Referral Form