Physician Referral Form - Renaissance Home Health

ADVERTISEMENT

Home Health Referral Form
Please fax this form with patient face sheet,
medication list, office note, and health history to:
Fax: 1-888-695-4686
Phone: 215-589-RHHC (7442)
Primary Care Physician: ____________________________
Todays Date: ___________________________________
Primary DX: _____________________________________
Patients Name: _________________________________
Secondary DX: ___________________________________
Date of Birth: ___________________________________
Referral Date: ____________________________________
SSN: __________________________________________
Health Insurance: __________________________________
Address: _______________________________________
Insurance ID #: ____________________________________
City:___________________________________________
Emergency Contact Name: __________________________
State and Zip Code: ______________________________
Emergency Contact Phone #:_________________________
Patient Phone #: _________________________________
* Please check all boxes below that apply *
Qualifying Services:
Specific Orders:
Additional Services:
 Registered Nurse
 Instruct & Assess Medications
 Wound Care (Specify)
 Physical Therapist
 Assess & Instruct Disease Process
 Social Worker
 Occupational Therapist
 Lab Work (Specify)
 Home Health Aide
 Speech Therapist
 Other (Specify)
Specify Items Listed Above: _____________________________________________________________
Face to Face Visit (Medicare Patients Only)
Face to Face Visit Date: ________________________________________________________________________
Reason for Home Care:_________________________________________________________________________
Physician’s Clinical Findings to Support Home Care Services: _________________________________________
__________________________________________________________________________________________
Physician’s Clinical Findings to Support Home Bound Status: ________________________________________
__________________________________________________________________________________________
I certify that this patient is under my care and I, or a Nurse Practitioner or Physician’s Assistant working with me, had a
Face-to-Face encounter requirements with this patient: The encounter with the patient was in whole, or in part, for the
following medical condition, which is the primary reason for home health care (LIST MEDICAL CONDITION):
Physician Signature (Required)
Physician Signature:
Date: ______________________
Physician Name (print):
Email: ____________________
Contact at Physician’s Office:
Phone: ____________________
NOTICE: The attached communication contains privileged and confidential information. If you are not the intended recipient, DO NOT read, copy, or
disseminate this communication. Non-intended recipients are hereby placed on notice that any unauthorized disclosure, duplication, distribution, or taking of
any action in reliance on the contents of these materials is expressly prohibited. If you have received this communication in error, please destroy all pages and
contact the sender. Renaissance Home Health E-fax is 1-888-695-4686.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go