Physician Referral Form - Renaissance Home Health printable pdf download

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.

Physician Referral Form - Renaissance Home Health

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