Patient Referral Form | Central Home Health Services of Texas

Patient Referral Form · Skilled Home Health

Tel (713) 378-0781
Fax (713) 461-5698
720 N Post Oak Rd, Ste 140
Houston, TX 77024 · centraloftexas.com
centralhhc@actiniumholdings.com

Instructions: Complete the form and add the provider signature, or print a blank form to fill out by hand. Email or fax the completed form to centralhhc@actiniumholdings.com or (713) 461-5698.

1 Patient Information

Patient last name Patient first name Date of birth (MM/DD/YYYY) Gender Social Security # (optional) Patient phone Patient address (street, city, state, ZIP) Emergency contact name & phone

2 Referring Provider / Facility

Physician / provider name Facility / practice name NPI number Phone Fax Address Contact person name Contact person phone / email

3 Insurance / Coverage

Primary insurance / payer Policy / member ID Medicare ID (if applicable) Secondary insurance Policy / member ID Medicaid ID (if applicable)

4 Service Requested

Skilled Home Health (Medicare / Medicaid / Private) Provider Attendant Services (PAS / Waiver)

Skilled Nursing (RN/LVN) Physical Therapy (PT) Occupational Therapy (OT) Speech-Language (SLP) Home Health Aide (HHA) Medical Social Work Personal Attendant (PAS) Other (specify below)

5 Clinical / Diagnosis Information

Primary diagnosis (ICD-10 code) Secondary diagnosis (ICD-10 code) Clinical notes / special instructions / precautions

6 Physician Signature & Authorization

I certify that I am the referring provider or an authorized designee. By checking this box and signing below, I certify the patient meets criteria for the services requested and authorize Central Home Health Services of Texas to initiate care and communicate with payers as necessary.

Provider signature

Date

Print name

NPI

Complete the form and add the provider signature, or print a blank form to fill out by hand. Email the completed form to centralhhc@actiniumholdings.com or fax it to (713) 461-5698.