Home Care Referral Form

Vital Health Home Care — Case Manager & Provider Referral

Submit a secure referral for home care services and upload any required documents as applicable.
Referral Source & Authorization
Referrer full name

First NameMiddle NameLast Name
Professional title / role
Organization
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Fax number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Relationship to person being referred
Organization type
Person Being Referred
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex / Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City, State, ZIP Code
County, NC
Payer / Program Information
Referral Source Type
Member / Participant ID
Managed Care Plan or Program Name
Funding Source
Eligibility / Authorization Details
Requested Home Care Services
Requested Service Types

Other
Referral Type
Start-of-Care Timing
Preferred Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requested Hours or Frequency
Preferred Days of Week
Service Preferences, Special Instructions, and Caregiver Support Needs
Clinical & Safety Details
Primary diagnosis or reason for referral
Relevant diagnoses or medical conditions

Other
Mobility and transfer needs

Other
Activities of daily living support needed

Other
Cognitive or communication concerns

Other
Behavioral or safety risks

Other
Certification & Submission
Typed signature (full legal name)

First NameLast Name
Administrative Details
Direct NPI
Preferred contact method
Guardian or authorized representative name

First NameLast Name
Guardian or authorized representative phone
Please enter a valid phone number.Format: (000) 000-0000.
Guardian or authorized representative email
example@example.com
Case Management Information
Case-management entity
Case manager name

First NameLast Name
Case manager phone
Please enter a valid phone number.Format: (000) 000-0000.
Case manager email
example@example.com
Authorization Details
Authorization number
Authorization status
Approved units or hours
Authorization effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization end date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Skilled Nursing Details
Signed order or prescriber
Requested nursing tasks
Skilled nursing frequency
Skilled nursing duration
Clinical Details
Allergies
Infection-control precautions
Equipment
Current location
Anticipated discharge date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Supporting Documents
Signed order

Cancelof
Service authorization

Cancelof
Person-centered service plan

Cancelof
Plan of care

Cancelof
Clinical notes supporting skilled services

Cancelof
Discharge summary

Cancelof
Insurance card

Cancelof
Other supporting documents

Cancelof
Submitter Name

First NameMiddle NameLast Name
Title / Role
Should be Empty:

Vital Health Home Care — Case Manager & Provider Referral

Referral Source & Authorization

Person Being Referred

Payer / Program Information

Requested Home Care Services

Clinical & Safety Details

Certification & Submission

Administrative Details

Case Management Information

Authorization Details

Skilled Nursing Details

Clinical Details

Supporting Documents