Phone 2:
Zip:
Gate Code/Landmarks:
Address 2:
How did you hear about HCD?
Referral Company:
Referral Contact:
Referral Phone:
PATIENT DEMOGRAPHICS
REFERRAL SOURCE
Contact Name:
Relationship to Patient:
Alt. Contact Phone:
Alt. Contact Email:
IN CASE OF EMERGENCY CONTACT
Name of Policy Holder:
Policy Holder's DOB:
Relationship to Holder:
Policy Number:
Group Number:
Secondary Insurance:
Policy Holder's DOB:
Relationship to Holder:
Policy Number:
Name of Policy Holder:
INSURANCE INFORMATION
Group Number:
PCP or PRN?
PCP Fax:
PCP Name:
PCP Phone:
Does patient have primary care physician or is patient PRN?
PCP Facility:
If PRN, Brielfy Explain the Situation in the box below:
Group Home Name:
Group Home Phone:
Does Patient Live in a Group Home or Facility?
Group Home Fax:
Agency Fax:
Agency Name:
Is Patient currently serviced by Hospice or Home Health?
Agency Phone:
PATIENT REFERRAL FORM
Does pt have any chronic illnesses or require any special skilled nursing needs? Briefly describe in box below:
* Required information
** Medicare part B only covers 80% of our services after the deductible is met. A supplemental (secondary) insurance may or may not cover the remaining 20%, so please provide additional information accordingly. House Call Doctors cannot accept patients with Medicaid as secondary and cannot bill dual-eligible patiens. If no supplemental (secondary) insurance is listed, a credit/debit card or check will be required; please include that information below.
Insurance phone:
Credit/Debit Card Information
Name as it appears on card:
Cardholder billing address & ZIP code:
Card number/ Expiration date/ Security code:
Social Security #:
Your Name:
Relation to patient:
