Get Referral And Intake Form - Home Care Amp Hospice - Visitingnurse

This guide provides step-by-step instructions for completing the Referral And Intake Form for Home Care and Hospice services. Filling this form accurately is crucial to ensure timely assistance and support for individuals in need of care.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to acquire the form and open it in an appropriate editor.
2. Begin by entering the patient’s name in the designated field labeled 'Patient Name.' Ensure the spelling is correct.
3. Provide the patient's date of birth in the 'DOB' field to establish age.
4. Indicate the patient's gender in the field provided; this step is optional and can be left blank if preferred.
5. Fill in the patient's street address in the 'Street Address' section, followed by the 'Town' or city name.
6. Input the patient's phone number to ensure proper communication.
7. If applicable, enter the patient's Social Security number in the 'SS#' field.
8. Specify the discharging facility, if relevant, in the field labeled 'Discharging Facility'.
9. Note the date of discharge in the corresponding space to track when services are needed.
10. Complete the field for the name of the person making the referral, ensuring all details are accurate.
11. Fill in the insurance carrier's name in the 'INSURANCE CARRIER' field along with the policy number.
12. List the primary diagnoses and surgery date, if applicable, in the designated area to inform care providers.
13. Provide the reason for the referral in the appropriate section clearly and concisely.
14. Indicate the medical doctor who will oversee the VNA home care plan and sign orders.
15. Select all requested services by marking the appropriate checkboxes, such as RN, PT, OT, etc.
16. Answer the question regarding Face-to-Face Encounter required for Medicare with 'Yes', 'No', or 'N/A'.
17. Ensure all required documents are faxed or emailed as mentioned in the list provided to complete the referral.
18. Lastly, enter today’s date in the 'Today’s Date' field before submitting the form.

Complete your Referral And Intake Form online today for prompt home care services.