Health Care Professionals
Do you have a patient in need of at home, skilled medical care? Print and fill out our quick referral page and fax it to us at (717) 263-3614. One of our courteous and friendly office staff will follow up with you. We can determine if an assessment is needed and get them started on the road to recovery!




PATIENT LAST NAME FIRST NAME
PATIENT'S ADDRESS
PHONE ZIP
EMERGENCY CONTACT PERSON PHONE
COMPLETE BIRTH DATE SEX MARITAL STATUS
  M F S M W Sep
HOSPITAL/INPATIENT FACILITY PHONE
ADMISSION DATE DISCHARGE DATE
PRIMARY PHYSICIAN'S NAME
PHONE FAX
INTAKE DATE:
   
REQUESTED 1ST VISIT DATE:
   
SOCIAL SECURITY NO.
   
PRIMARY INSURANCE
   
OTHER INSURANCE
   

 

I certify that this patient is under my care and I, the referring physician, a nurse practitioner, or physician's assistant working with me, had a face to face encounter (FFE) with this patient.

 

Date of FFE:  
Skilled Nursing Physical Therapy
Medical Social Worker Occupational Therapy
Home Health Aide Speech Therapy

 

My clinical findings that support the need for the above mentioned home health services are as follows:

 

  I certify my clinical findings support that this patient is homebound per CMS guidelines due to:

 

Special Instructions:  
Physician's Signature: Date:
   

Testimonials


"Many thanks for all of your TLC. I truly enjoyed your girls and miss everyone. I wouldn't have gotten this far without your help!"
"You all were so great, with such loving care, smiles and concern for her well being and recovery. You all are just simply amazing and we will never forget the great care and love that you shared. You all made us feel special and do a great job at what you do."
"Very professional; took time to address each concern and explain it in terms we could understand"
"She was very excellent and I really liked her cooperation and generosity. She was very exceptional and I hope she treats her other patients as well as she did me."
"Did a great job. He is caring and a good person. My experience during my care was the best. I think that he is a great asset to your company and should be commended."
"All services were performed in an outstanding manner. You could not ask for better people to work with."
"Very knowledgeable and gave many helpful suggestions. We know she cared about us."
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