Your Choice Home Care eReferral Form

Your Choice Home Health Care, Inc

2001 Zinfandel Drive A3, Rancho Cordova, CA 95670 PHONE: (916) 476-6037 FAX: (916) 706-0108
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
Medicare / Insurance #
Primary Language
Allergies
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Diagnosis
Height
Weight
Gender

FemaleMaleOther
I certify that this patient is under my care and that I had a face-to-face encounter with this patient on: Date
I certify that the following services are medically necessary for home care services:

Skilled NursingPhysical TherapyOccupational TherapyRegistered DieticianSpeech TherapyHome Health AidMedical Social WorkerOther
My clinical findings from this encounter support the patient is homebound to:

Needs assistance for all activitiesRequires assistance to ambulateUnable to safely leave home unassistedDependent upon adaptive device(s)Residual weaknessConfusion, unable to go out of home aloneSevere SOB, SOB upon exertionMedical Restriction
The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home health care.
Certifying Physician Name

First NameLast Name
NPI #
Phone:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Certifying Physician Signature

Clear
Please provide patient's history, physical, current medications and progress notes for the last 90 days. Attach files securely below or fax to (916) 382- 9941

Cancelof
Should be Empty:

Your Choice Home Health Care, Inc