REFERRAL SAMLAND HEALTH CARE INC.

Home Health Referrals

If you are a physician's office, Hospital, Nursing Home or Insurance Company, please fill out the following information to e-mail us a referral now or you can download the REFERRAL FORM in .PDF format by clicking on this link and faxing it to(773)283-7595 or (773) 202-4747(Get Adobe Acrobat Reader)

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SAMLAND Home Health Services Referral Form:

 * Required fields
*Physician Name :
*Physician Phone # :
*Patient Last Name :
*Patient First Name :
*Patient Address :
*City :
*State :
*Zip Code :
*Patient Phone # :
*Date of Birth :
Social Security # :
HIC # :
Relationship :
Contact Person :
Contact Phone # :
Diagnosis :
Allergies :
Services Ordered :
 (Please check all that apply.)
RN
 Physical Therapy
RN Assess & Call Physician For Orders
 Occupational Therapy
MSW
 Speech Therapy
AIDE
Case Manager:
Private Insurance:
 (Please provide the following.)

Insurance Co :
Insurance Phone #:
Policy Holder :

Policy # :
GRP :

Specific Orders :

 (Eval & Call, Meds, Diet, Labs, Etc.)
Medicare patients are homebound and in need of intermittent care.
DME Required :
Physician Office Contact :
   
  Admission Services Occupational Therapy
  Cardiovascular Pharmacy Services
  Pulmonary Services Physical Therapy
  Diabetes Respiratory Therapy
  Wound Care Skilled Nursing
  Home Care Aides Speech Language Pathology
  Psychiatric Medical Social Services
   
   

 
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