Home Health Referral

FACE SHEET

Patient Name

Referral Date

DOB

Phone

Gender
MaleFemale

Address

City

State

Zip

Alternate Contact

Contact Number

Relationship

Payer

MedicareMedicaidCommercial / Medicare AdvantageOther

Policy #

Group #

Referring Primary Care Provider

Phone

Referring Facility

Primary Care Provider for home health orders

Diagnoses

LAST FACE TO FACE ENCOUNTER

Visit within past 90 days?
YesNo

Face-to-Face Encounter Date

Along with this completed form, please attach the most recent document, clearly signed and dated by the Primary Care Provider, detailing the reason for recommending Home Health services along with this completed form.

Examples of acceptable documents include: progress note, history and physical, or discharge summary.

PRESCRIBED ORDERS FOR PATIENT CARE

Skilled Nursing

Medication management and teachingDisease management and teachingObservation and assessment

Physical Therapy

Coordination / StrengthROM exerciseEndurance / balanceGait training

Occupational Therapy

Safety at homeDME use/needAbility to do ADLs

Speech Therapy

Assessment and EvaluationsAspiration prevention

Medical Social Worker

Living situation / support system / community resources

CHHA (certified home health aide)

Provide / assist with personal care for incontinence

Specialty Programs

Fall PreventionChronic Disease Management Program (CHF / Diabetes / COPD)

Primary Care Provider’s Name

Date

HOMEBOUND STATUS

Homebound
YesNo

Patient is confined because of illness, needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or assistance of another person to leave the home OR has a normal inability to leave home.

Leaving home requires a considerable and taxing effort for the patient. Specify: patient requires assistance to leave home due to pain, instability. I certify that the patient is confined to the home and needs intermittent skilled nursing care/therapy care.

Home Health Referral Form