Refer a Patient to Home Health Today Patient Home Health Refer a Patient to Home Health TodayPlease 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:Name* Phone*Email* PATIENT INFORMATION:First Name* Last Name* MI if applicable: Patient’s Date of Birth* MM slash DD slash YYYY Address* City* County* State* Zip Code* Questions or CommentsINSURANCE *Insurance*Max. file size: 50 MB.Plan#1: Policy No: e.g.) MedicarePlan#2: Policy No: (e.g.) AARP/MedicalOthers: Policy No: (e.g.) Private InsuranceEMERGENCY CONTACTName* Phone*PRIMARY DIAGNOSIS:For Home Health* MEDICALLY NECESSITY HOME HEALTH CARE SERVICESCheckboxes Skilled Nursing Occupational Therapy Physical Therapy Speech Therapy Home Health Aide Medical Social Worker MEDICAL RECORDS/ MEDICATIONUpload/fax if possibleMax. file size: 50 MB.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 Month* Day* Year* 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):Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY CHECK BOX IF NEXT DAY VISIT NEEDED Fax: (925) 684-4193 Questions? Call: (925) 634-7878 Email: [email protected] Δ
