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Doctor’s Office Referral Form

Intake Fax#: 844 581 0861                Phone#: 916 482 0700

    Information to be Faxed with Referral:

    Demographics/Insurance InfoMedications ListH&POffice Note

    Patient Information:

    Name:

    DOB:

    MaleFemale

    Phone:

    Alternate Phone, if any:

    Email Address:

    Address (where services provided):

    Street:

    City:

    State:

    Zip code:

    Mailing Address (if different than service address):

    Street:

    City:

    State:

    Zip code:

    Emergency Contact:

    Relationship:

    Phone:

    Alternate Phone, if any:

    Referring Physician:

    Phone:

    Primary/Attending Physician:

    Phone:

    Primary Diagnosis:

    Secondary Diagnoses:

    Allergies:

    Next scheduled office visit:

    Service(s) Needed:

    Skilled NursingPhysical TherapyHome Health AideOccupational TherapySpeech TherapySocial Worker

    Treatment Orders:

    Referral Contact Person and Phone #

    Physician Signature & Date for HH Referral Order:

    “Face To Face Encounter” (F2F) Documentation for Medicare Patients

    I, or a nurse practitioner or physician’s assistant working with me, had a face-to-face encounter with this patient that addressed the primary reason for home health care.

    Date of the F2F visit

    Reason for home health care:

    Clinical Findings to support the need for home health services:

    Patient is homebound because:

    Physician Signature:

    Date:

    Physician Name Printed:

    Thank You for your Referral!