Sunrise Home Health Care

PHYSICIAN REFERRAL

Harmony Homes of Miami coordinates client care and services to ensure appropriate continuity of care and services from admission to discharge.

We work in coordination with the primary care physician to ensure that in between office visits, or through critical stages of treatment, the patient is cared for in a manner consistent with the wishes of the physician.

Referrals are received from, but not limited to, the Physician or his/her staff, a facility discharge planner, case manager/medical social worker, community agency, the client or the client's family.

Referrals may be received in person, by telephone or via facsimile and are taken by a licensed professional staff.

Treatment visits will be made within 24 hours (or sooner) of referral, if required.

Today's Date:	2011-06-24
Patient Name:*
Telephone:*
Date of Birth:*
Address 1:*
Address 2:
City:*
Zip Code:*
Social Security#:* (last 4 digits only)
Insurance Information:*
Contract #:*
Group #:*
Diagnosis:*
Additional Orders/Special Instruction:*
For Pre-Surgical Instructions, Please Describe:*
Skills needed:*	Skilled Nursing Speech Therapy Physical Therapy MSW Occupational Therapy Home Health Aide Private Duty
Physician's Name:*
NPI #:*
Office Contact:*
Physician's Telephone:*
Fax:*
Email:*
Please indicate how you wish to receive confirmation of receipt of the submitted physician referral form.	Physician's Telephone Fax Email

* (indicates required field)