Physician Referral

PRINT REFERRAL FORM 

    Patient Basic Information
    Last Name: First Name:
    D.O.B:
    Patient Address:
    City: State: Zip:
    Patient Phone Number:
    Secondary:
    Caregiver:
    Relationship:
    Phone Number:
    Care Plan Oversight
    Will the Ordering Physician Sign and Oversee the Plan of Care?
    YesNo If No, which physicain will sign and oversee the paln of care?:
    DR:
    Patient Insurance
    Medicare:
    Medicaid:
    BXBS:
    Other:
    Physician Ordering Services
    Dr:
    Phone:
    Fax:
    Address:
    NPI#
    PECOS Registered? YesNo
    Services Ordered Diagnosis
    Choose one box with your order for SOC date:
    SOC on a specific
    Within 48 hours of SOC referral
    The following services are medically necessary:
    Skilled Nursing Physical Therapy Speech Therapy
    Occupational Therapy Home Health Aide Social Worker
    VERIFICATION OF PHYSICIAN AND PATIENT FACE-TO-FACE ENCOUNTER (MUST BE COMPLETED)
    DATE OF PHYSICIAN ENCOUNTER
    MEDICAL REASON FOR ENCOUNTER:  
     
    CLINICAL FINDINGS:
     
    REASON PATIENT IS HOMEBOUND:
    (examples: leaving home is a taxing effort, patient is unable to leave home unassisted or due to medical restrictions)
     

    Signature of Physician or NPP who performed Face-to-Face encounter and informed certifying Physician if needed:

    DATE:
    I certify that this patient is under my care and that I have had a Face-to-Face encounter that meets Physician Face-to-Face requrements with the patient noted above.
    Content of form based on CMS Calendar Year 2011 Final Rule Face to Face encounter requirments. *NPP- Non Physician Practitioner or clinical Nurse specialist in collaboration with Physician or Physician Assistant under the supervision of the Physicain who will oversee the Plan of Care

     

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