Home Health Services Referral Form

THIS ONLINE FORM IS HIPPA COMPLIANT

Patient:*

First NameLast Name

Reason for Encounter:

I certify that I, or a qualified non-physician practitioner working with me, had a face-to-face encounter with this patient on the date indicated below due to the medical condition also listed below, which relates to the primary reason the patient requires home health services.

Encounter date:

Date

Diagnosis/Reason:

I certify based on my findings, the following: (choose section A or B)

A. Home health services are medically necessary for this patient:

Nursing servicesPhysical therapyOccupational therapyHome Health Aide

B. This patient is homebound based on the following:

My clinical findings support the need for the above services because:

I certify that this patient is under my care, or has been referred to another physician having professional knowledge of the patient’s condition. Services ordered above are needed to treat condition for which patient was hospitalized and/or seen in the office. The composed above information is based on my clinical judgment relating to this patient’s medical condition.

Certifying physician signature:

Physician name:

First NameLast Name

Date:

Date

HIPAA Privacy Notice for Online Form Submissions
Global Care of Massachusetts
Effective Date: April 30, 2025

Your Health Information Privacy is Important to Us

This notice explains how your health information may be used and disclosed by Global Care of Massachusetts when you submit information through our online forms. It also describes your rights regarding this information. Please read carefully.

Use and Disclosure of Your Health Information
When you complete and submit an online form, you may be providing Protected Health Information (PHI), which is any individually identifiable health information protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

We may use and disclose your PHI for the following purposes:

Treatment: To coordinate and manage your home health care services with nurses, therapists, or other care providers involved in your care.
Payment: To bill Medicare, Medicaid, private insurance, or other third-party payers for the services you receive.
Health Care Operations: For internal operations such as quality assessment, training, licensing, and audits to ensure we provide safe and effective care.
Required by Law: We may disclose your information when required by federal, state, or local law, such as to report abuse, neglect, or to comply with court orders.
We will not use or share your information for marketing or fundraising without your express written permission.

Your Rights
You have the right to:

Request a copy of the information you’ve submitted.
Ask for corrections to any inaccurate or incomplete information.
Request limits on how we use or share your information.
Receive a list of certain disclosures we’ve made of your information.
File a complaint if you believe your rights have been violated.
You can make any of these requests by contacting us directly at the information below.

How We Protect Your Information
We take your privacy seriously. Information submitted through this online form is transmitted securely using encryption and is stored in compliance with HIPAA security standards. Access to your PHI is limited to authorized personnel only.

Contact Us
If you have any questions about this notice or your privacy rights, please contact:

Global Care of Massachusetts
10 Forbes Road
Suite 155 East
Braintree, Massachusetts 02184
Phone: 774-240-8146
Email: services@globalcarellc.org

10 Forbes Road • Suite 155 East • Braintree, MA 02184
P: 774-240-8146 • F: 7742728378 • services@globalcarellc.org

Home Health Services Referral Form

PATIENT DEMOGRAPHICS

PRIMARY CONTACT

INSURANCE INFORMATION

SERVICES

IV INFORMATION

CURRENT IV ACCESS

FACE-TO-FACE ENCOUNTER CERTIFICATION