Patient Referral Form

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4701 Patrick Henry Drive, Suite 2601
Santa Clara, CA 95054
Phone: (408) 650-7110
Fax: (408) 608-1917
PATIENT REFERRAL FORM
PATIENT INFORMATION (please attach face sheet)
Patient’s First and Last Name:
Male
Female
Address:
City:
Zip:
Phone:
DOB:
SS#:
Alt. Phone:
INSURANCE INFORMATION (please attach insurance card copy)
Medicare#:
Medi-Cal #:
ID#:
Group#:
Subscriber:
Private Ins.:
PERTINENT PATIENT HEALTH INFORMATION (please attach notes, medical history and/or medications)
Primary Dx:
Other Dx:
Surgeries/Procedures and Dates:
Medical Reason for Home Health Request:
Start of Care Date Requested:
Disciplines Requested: RN
PT
OT
ST
MSW
HHA
Companion Care (Caregiver): Out of pocket/Long-term care insurance service for assistance with personal care,
meal prep, light housekeeping, transportation, and companionship. Someone will contact your patient directly to set
up a FREE, no obligation assessment to explain our services.
PHYSICIAN INFORMATION
Physician’s Name:
Address:
City:
Zip:
Phone:
Fax:
NPI #:
UPIN #:
PHYSICIAN RESPONSIBILITIES
1. SIGN ORDERS: The Home Health Certification and Plan of Care (HCFA 485) required by regulation and for
reimbursement. Physician signature is required on this form within 30 days of start of care home health
services, and indicates physician’s agreement that patient meets regulatory program criteria (homebound.
skilled need, medical necessity).
2. CHANGE IN PLAN OF CARE: Additional orders by physician require signature within 30 days of order.
3. PHYSICIAN COVERAGE: When not available, please provide alternate physician coverage.
4. DRUG REGIMEN REVIEW: Required by CMS within 24 hours of start of care, along with initial agreement to
clinician plan of care
I certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me or a
physician who cared for the patient in an acute or post-acute facility had a face-to-face encounter related to the primary
reason the patient requires home health that meets CMS requirements with this patient on _________________________.
(date the face-to-face visit occurred)
Physician Signature: ______________________________________________________________________ Date: _______________________________

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