Community Paramedicine Referral Form

Community Paramedicine Home Visit Program

Referral Form
Date:*

MonthDayYear
Referred by (Name/Title):*
Phone Number:*
Fax Number:*
Please enter a valid phone number.
PCP Office:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Name:*

First NameLast Name
Patient DOB:*

MonthDayYear
Date
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone:*
Patient Email:
Insurance Information:
PCP Signature:*

Clear
Program was discussed with patient:

YesNoN/A
Reason for Referral*
Past Medical History: (Please include medication list or upload below)*
Please Include Medication List:

Cancelof
Past Surgical History
Number of Visits Requested:*
Type a Services Requested: (Check all that apply)*

Available Resources and SeriesMedication Compliance & ReconciliationWell-being Visits (Bi- Weekly/Monthly)Activities of Daily Living AssessmentChronic Disease Monitoring / ManagementVital Sign CheckChronic Disease EducationMaine CDC ASME (In-Home Asthma Education Program)Wound Check / CareCLIA Waived Testing (see below for tests)LAB ORDERS (see below for uploading lab ordersOther
CLIA Waived Testing: (Check any needed)

FluPregnancyMonoStrep AUrinalysisRSVA1COther
LAB Orders:

Cancelof
Any additional/ background information: (Living situation/Challenges/Disabilities)
If questions, contact:

United Ambulance Service Community Paramedicine

192 Russell St. Lewiston, ME 04240

prevention@unitedambulance.net

Phone: 207.777.6000

FAX: 207.777.6008
Should be Empty:

Community Paramedicine Home Visit Program