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Name
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First
Last
DOB (MM/DD/YYYY)
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Phone Number
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Address
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Line 1
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City
State
Zip Code
Country
Do you have a doctor's order for home health? (If not, we can certainly check if the patient is eligible for home health but we cannot start any services until a signed doctor's order is received.)
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Yes
No
If not, we can certainly check if the patient is eligible for home health but we cannot start any services until a signed doctor's order is received.
Does the Patient Have Medicare? (If not, what type of insurance does he/she have? (If not, we can certainly check if the patient is eligible for home health but we cannot start any services until a signed doctor's order is received)
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Yes
No
Insurance Company
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Medicare/Policy #
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Referral Source Name
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First
Last
Referral Source Email
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Referral Source Phone Number
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Other Information
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If you have a history and physical, the doctor's order, or any other documentation for the patient, you can either fax it to us at 909-948-8736 or email us at ihhpie@gmail.com. We will promptly confirm receipt of the documents once we get them.
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Home
About Us
Our Services
Careers
Contact Us
Resources
News
General Resources
Home Health Resources
FAQ
Testimonials
Patient Referral