4701 Patrick Henry Drive Bldg 1 Suite 1107 (408) 650-7110 Info@InTouchHHC.com

Referral Form

Contact us

Referral Form

    Insert Option: Please Attach Your Files (e.g., face sheet, insurance card)


    PATIENT INFORMATION (please attach face sheet)









    INSURANCE INFORMATION (please attach insurance card copy)





    PERTINENT PATIENT HEALTH INFORMATION (please attach insurance card copy)







    PHYSICIAN INFORMATION (please attach notes, medical history and/or medications)







    PHYSICIAN RESPONSIBILITIES

    1. SIGN ORDERS: The Home Health Certification and Plan of Care (HCFA 485) required by regulation and for reimbursement. Physician signature is required on this form within 30 days of start of care home health services, and indicates physician’s agreement that patient meets regulatory program criteria (homebound, skilled need, medical necessity).

    2. CHANGE IN PLAN OF CARE: Additional orders by physician require signature within 30 days of order.

    3. PHYSICIAN COVERAGE: When not available, please provide alternate physician coverage.

    4. DRUG REGIMEN REVIEW: Required by CMS within 24 hours of start of care, along with initial agreement to clinician plan of care.

    I certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me or a physician who cared for the patient in an acute or post-acute facility had a face-to-face encounter related to the primary reason the patient requires home health that meets CMS requirements with this patient on: