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.
Patient Name

M  FPlease complete this information (or attach demographics /face sheet) and office visit note. Fax to: (210) 469-4026.
Patient Name
SSN Last 4
Date of Birth

MonthDayYear
Date
Address
Phone
City, State, Zip
Alternate Contact Name
Last Flu Vaccine Date

MonthDayYear
Date
PATIENT
Alternate Contact’s Number
Referral Date

MonthDayYear
Date
Primary Care Physician
Insurance Information: (or attach copy)
Office Contact Name
Office Contact Number
DIAGNOSIS ICD-10-CM Codes / MEDICAL CONDITION: List the diagnosis / medical conditions primary to home health care
HgbA1C Date

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

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

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

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

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

Home Health Aide:
Physical Therapy for
Social Work
Speech Therapy for
Home Health Aide
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
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
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
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
Physician’s Name/NPI#
Physician Signature
Signature Date

MonthDayYear
Date
OPTIONAL PHYSICIAN DOCUMENTATION
This section is provided for the physician’s convenience and record keeping in the event of a Medicare audit.
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

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