Refer a Patient: Doctor's Referral

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Fields marked by an asterisk (*) are required.

Patient Information

* Patient First Name: * Patient Last Name:
* Address: * Phone:
* City:   Email:
* State: * Social Security #:
* Zip: * DOB:

Next-of-kin Information

* Next of Kin: * Relationship:
* Address: * Phone:
* City:   Email:
* State:      
* Zip:      

Physician Information

* Name: * Phone:
* UPIN: * Email:

Insurance Information

* Insurance: * Policy #:
* Phone:   Group #:
  MediCaid #:   MediCare #:

Source of Admission Code

1 Physicians Referral 7 Emergency Room
2 Clinic Referral 8 Court/Law Enforcement
3 HMO Referral 9 Information not Available
4 Transfer from Hospital A Transfer from Critical Access Hospital CAH
5 Transfer from SNF B Transfer from another Home Health Agency
6 Transfer from another Health Care Facility C Readmission to same Home Health Agency

Diagnosis(es)
Surgical Diagnosis(es)

A. A.
B. B.
C.  
D.  

Emergency Plan Category
1 2 3

Orders


Staff Contacted

SN   Date:
PT   Date:
OT   Date:
SLPT   Date:
MSW   Date:
HHA   Date:

Patient/Caretaker contacted by Nurse/Therapist:
Verified by:
Date:

Evaluate and Treatment Frequency:

Name of Person taking Referral:
 
  Time:

Name of Physician:
 
  Time:

Verify the above information and submit to refer a patient to Austin Home Health.


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