Home Health Referral Form

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Home Health Referral Form

PathWell Home Health & Hospice
Office Address: 118 Creekside Ln, Winchester, VA 22602
Phone: (540) 450-8680 | Fax: (540) 450-8638
Email: VA: intake-va@pathwellhealth.com | WV: intake-wv@pathwellhealth.com

FKA Caring Angels, Countryside Home Health and Hillside Hospice Serving Northern Virginia and Northeast West Virginia

Email *

Record my email address with my response

Note: A face to face encounter can be completed by a Physician's Assistant and/or Nurse Practitioner but all home health orders must be co-signed and dated by a physician

Patient Name
*

Patient's Phone:
*

Date of Birth
*

YYYY

Patient's Insurance
*

Referring Physician
*

Physician's Phone:
*

Physician's Fax:
*

Face to Face encounter related to current needs for Home Health occurred on
*

YYYY

Patients Primary Dx(s) and reason for Home Health

Note: Symptom dx codes cannot be used for home health referrals

✔️Check primary discipline(s) being ordered *

Skilled Nursing

Physical Therapy

Occupational Therapy

Speech Therapy

Required

Additional Evaluations

(✔️Check any/all that apply. Must be in addition to SN or PT)

Occupational Therapy

Physical Therapy

Speech Therapy

Medical Social Worker

Home Health Aide

Required Documents
1. Patient demographics, including insurance information

2. Most recent F2F visit note from physician

3. Most recent H&P, listing primary dx and comorbidities

4. Current medication list

I will ensure that these documents are sent through Fax/Email provided at the top of the form

Required

Required: Homebound Status Certification

Due to the above stated illness, injury or surgical procedures (medical condition or diagnosis) and associated clinical findings, I certify that the patient is homebound because of his/her inability to leave the home except with the aid of a supportive device and/or person AND leaving the home requires a considerable and taxing effort or is medically contraindicated.

Required

Required: Please complete this table to meet homebound eligibility criteria

Patient requires the following assistance to leave the home
(✔️Check any/all that apply)

Cane

Walker

Wheelchair

Aid of another person

Medically Contraindicated

Required

Physician Signature

Send me a copy of my responses.

Submit

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