Refer a Patient

Referring a patient to us means entrusting them to a team that values compassion, expertise, and personalized attention. Let us extend our care to those you care about. Thank you for choosing Home Health Professionals, where every patient is treated like family.

Physician Name

Physician Address

Physician Phone

Physician Fax

City

Contact Name

Date

Patient Name

Patient Date of Birth:

Primary Diagnosis/ICD 10 Code

Surgery Date

Evaluate for home health services / Assess and Treat as Necessary.

Area

R L

Area

Surgical Procedures:

Demographics

History & Physical

Clinical Notes/ Discharge Summary from date of face-to-face encounter

I certify that this patient is under my care and that I, or a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse-midwife working in collaboration with me or under my supervision, had a face-to-face encounter that meets the physician face-to-face encounter requirements with this patient and the patient is homebound.

Date of Last MD F2F Encounter:

DC Summary and/or progress note supporting homebound status attached

The encounter with the patient was directly related to the following medical condition, which is the primary reason for home health care: (choose one)

Describe Safety eval S/P surgery/Other

The following clinical findings support that the patient is homebound and that the patient requires skilled nursing and/or therapy: (mark all that apply)

Describe S/P surgery precautions:/Other

Statement of Homebound Status: (mark all that apply) I certify that my clinical findings and the patient’s medical condition supports that this patient is homebound due to:

Residual weakness Needs assistance for all activities Requires max assistance / taxing effort to leave home Unable to safely leave home unattended Severe SOB or SOB upon exertion Confusion, unsafe to go out of home alone

CERTIFYING PHYSICIAN SIGNATURE:

Date

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Thank you
for choosing Home Health Professionals

We deeply appreciate your trust in us to provide you and your loved ones with the highest quality home health care. At HHPros, we are committed to exceeding your expectations by delivering compassionate, personalized care tailored to your specific needs. Your confidence in our services motivates us to continue striving for excellence in everything we do. We look forward to being a part of your health journey and are here to support you every step of the way. Thank you for being a valued member of our HHPros family.

Refer a Patient

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Thank you for choosing Home Health Professionals

Thank you
for choosing Home Health Professionals