+240-801-9818
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Home Healthcare Referral -
Outpatient Rehab at Home
Thank you for your referral! Please fax this referral sheet with the following:
H&P / Discharge Summary
,
Current Medication List
and
Medicare patients only: completed Medicare Certification ("Face to Face")
Phone:
(240) 801-9818
HIPAA Fax:
240-801-9819
Patient Demographics
First Name:
Middle Name:
Last Name:
Date of Birth:
Sex:
Male
Female
Home Phone:
Mobile Phone:
Home Address:
Street:
City:
Zip Code:
Service Location:
(if not home address)
Street:
City:
Zip Code:
Caregiver / Emergency Contact:
Phone:
Insurance:
Medicare B
Medicaid
Carefirst
Cigna
ID #:
Diagnoses:
Home Health Orders and Respite Care
Please check all home health services ordered:
Skilled Nursing, Evaluate & Instruct:
Cardiac
Home Health Aide
Advanced Illness Management (AIM) / Palliative Care
Wound Care
Diabetes
Medication Management
Respiratory
Type
Location(s)
Stage
Physical Therapy, Evaluate & Instruct:
Ambulation / Gait
Bed Mobility
Safety / Falls
Weakness / Strengthening
Other
Wheelchair Mobility
Balance
Range of Motion
Transfers
Speech Therapy, Evaluate & Instruct:
Cognition
Language Processing
Other
Swallowing
Voice Intelligibility
Hearing
Medical Social Work, Evaluate & Instruct:
Note:
To order MSW, either skilled nursing, physical therapy, or speech therapy must also be ordered.
Family Support System
Stress/Coping/Grief
Unsafe Environment
Other
Counseling Referral
In-Home Assistance
Alternate Living
.
Occupational Therapy, Evaluate & Instruct:
ADLs
Energy Conservation
Other
Sensory Dysfunction
Orthotics
Equipment & Adaptive Devices
Patient Specific Parameters:
(Use the following patient specific parameters to notify the physician of patient changes)
BP (>/<)
Pulse (>/<)
Resp(>/<)
Temp (>/<)
02 SAT (>/<)
Weight (+/-)(>/<)
Comments:
Physician Information
Referring Physician:
Phone:
Fax:
Following Physician:
Phone:
Fax:
Physician Signature:
(By signing, I am confirming referral orders and diagnosis listed.)
Date: