Refer a Patient to Home Health Today

Patient Home Health

  • Refer a Patient to Home Health Today

  • Please provide the following information needed for evaluation and possible admission to Amavi Home Health and Hospice Care Services. As another option you can download the PHYSICIAN REFERRAL ORDER and fax the completed form to: (925) 684-4193.
      Questions? Call: (925) 634-7878
    Email: [email protected]
  • PHYSICIAN INFORMATION:

  • PATIENT INFORMATION:

  • Date Format: MM slash DD slash YYYY
  • INSURANCE *

  • e.g.) Medicare
  • (e.g.) AARP/Medical
  • (e.g.) Private Insurance
  • EMERGENCY CONTACT

  • PRIMARY DIAGNOSIS:

  • MEDICALLY NECESSITY HOME HEALTH CARE SERVICES

  • MEDICAL RECORDS/ MEDICATION

  • IF PATIENT IS ON MEDICARE:
    The F2F encountered date must be within 90 days prior or 30 days after the date of the home care admission and related to the reason for the home care referral

    I certify that this patient is under my care and that I or a Nurse Practitioner or Physician’s Assistant had a face to face encounter on
  • IF PATIENT IS ON MEDICARE:
    Certification of Home Health Services:
    Based on the above finding, I certify this patient is confined to the home and needs intermittent skilled nursing, physical, speech or occupational therapy. The patient is under my care, and I have initiated the establishment and will periodically review the plan of care. I will provide the agency additional information to support the patient’s homebound status and need for skilled care. Examples of this information could include physician progress notes, history and physical forms, operative reports, discharge summaries, etc.
  • PHYSICIAN ELECTRONIC SIGNATURE (eSign):

  • Date Format: MM slash DD slash YYYY
  • Fax: (925) 684-4193
    Questions? Call: (925) 634-7878
    Email: [email protected]

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(925) 684-7979
(925) 256-4960
(925) 634-7878
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