ADMT Solutions Home Health Referral Form

ADMT Solutions Home Health

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.
Referral Date

MonthDayYear
Date
PATIENT INFORMATION
Patient Name
Male or Female
SSN
Date of Birth

MonthDayYear
Date
Patient Phone
Format: (000) 000-0000.
Street Address
City, State, Zip
Alternate Contact Name
Alternate Contact’s Number
Last Flu Vaccine Date

MonthDayYear
Date
Primary Care Physician
Insurance Information: (or attach copy below)
Insurance name & ID#
Office Contact Name
Office Contact Number
Primary Diagnosis Code and Condition: List the diagnosis / medical conditions primary to home health care
Skilled Services Needed
Describe need for Skilled Nursing
Describe need for OT
Describe Need for PT
Describe Need for Social Work
Describe need for Speech Therapy
Describe the need for Home Health Aide
ADDITIONAL ORDERS
wound care, picc line, etc
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.)
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
Enter Face-to-face Date
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#
Signature
Signature Date

MonthDayYear
Date
OPTIONAL PHYSICIAN DOCUMENTATION
Upload Face Sheet, Clinicals, and/or Progress Notes

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Upload Insurance Information or Card

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Should be Empty:

ADMT Solutions Home Health

PATIENT INFORMATION

CERTIFICATION FOR FACE-TO-FACE ENCOUNTER