Home health referral form template 2025

1. Click ‘Get Form’ to open the home health referral form template in the editor.
2. Begin by filling out the patient information section. If you have the patient's face sheet, you can skip this part. Enter the last name, first name, middle initial, address, city, zip code, and phone numbers.
3. Next, provide the patient's date of birth, age, marital status, sex, social security number, and insurance details including Medicare and Medi-Cal numbers.
4. In the diagnosis section, list any relevant diagnoses for the patient. You can add up to five entries as needed.
5. Select the required services from the orders section by checking the appropriate boxes for home health care evaluation or therapy services.
6. For medications and injectables, ensure to fax the MD’s prescription along with appropriate diagnoses listed in this section.
7. Complete additional information regarding allergies and vaccination dates as necessary.
8. Finally, certify that all information is correct by signing at the bottom of the form and providing your medical details.

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