Home Health Referral Intake

Home Health Referral Intake

Complete the fields below.
Referral Source Information
Referral Source / Facility
Contact Person
Referral Source Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source Fax Number
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Demographics
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Primary Language
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City / State / Zip
Patient Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name & Number
Insurance and Provider Information
Primary Insurance
Policy Number
Secondary Insurance
Medicare Number
Medicaid Number
Primary Care Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Fax Number
Physician NPI Number
Clinical History and Referral Reason
Primary Diagnosis
Secondary Diagnosis
Hospitalization within last 30 days
Reason for Home Health Referral
Medication Management Needed
Home Environment and Safety
DME Equipment in Home
Allergies
Current Medications Attached
Does patient live alone
Caregiver Available
Fall Risk
Home Environment Safe
Pets in Home
Any Safety Concerns
Care Coordination and Additional Notes
Requested Start of Care Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Aware of Referral
Consent to Contact Patient Obtained
Hospital Discharge Date (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Notes
Should be Empty:

Home Health Referral Intake

Referral Source Information

Patient Demographics

Insurance and Provider Information

Clinical History and Referral Reason

Home Environment and Safety

Care Coordination and Additional Notes