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HOME HEALTH REFERRAL
Peace & Harmony Home Health · 620 N. Brand Blvd., Suite 200, Glendale, CA 91203
FAX 747-262-1677
Intake 747-262-1676
Patient
Last name
First name
Date of birth
Phone
Address (street, city, ZIP)
Primary language
Emergency contact / relationship / phone
Insurance
Primary insurance
Member ID
Secondary insurance
Member ID
Orders
- Skilled nursing (SN) — evaluate & treat
- Physical therapy (PT) — evaluate & treat
- Occupational therapy (OT) — evaluate & treat
- Speech-language pathology (ST) — evaluate & treat
- Medical social work (MSW)
- Home health aide (HHA)
- Wound care — see instructions
- Other: ____________
Primary diagnosis (ICD-10)
Other diagnoses
Homebound due to
Specific instructions (wound care, parameters, DME, precautions)
Allergies
Code status
Face-to-face encounter
Encounter date
Performed by (name / credentials)
Within 90 days before or 30 days after start of care; related to the primary reason for home care.
Referring / certifying practitioner
Name / credentials
NPI
Practice / facility
Phone
Fax
Contact person
Signature
Date
Attached
- Face-to-face note
- H&P / discharge summary
- Medication list
- Demographics / face sheet
- Insurance card copy
- Wound / therapy notes