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TheraCare Referral Form and Order
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About TheraCare
When are Home Health Services Needed?
TheraCare Services
Coverage Area
Helpful Information
Refer a Patient to Home Health Care
Patient First Name
*
Patient Last Name
Date of Birth
Social Security Number
Street Address
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
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Kentucky
Louisiana
Maine
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Massachusetts
Michigan
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Montana
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New Hampshire
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Ohio
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Zip Code
Phone
Alternate Contact
Insurance Information
Insurance Provider
Member ID#
Group #
Policy #
Primary Policy Holder
Relationship to Patient
Orders
Primary Recommendations
Skilled Nursing
MSW
Physical Therapy
Occupational Therapy
Speech Therapy
Home Health Aide
Additional Recommendations
Fall Prevention Program
Total Joint Program
Spine Program
Pain Interventions
Depression Interventions
HF/COPD/HTN Program
Wound Care
Diabetes Management/Foot Care
Other
Medicare Encounter Documentation
Diagnosis related to primary need for home care
Clinical findings that support the need for home health (specific need for nursing and/or therapy services).
Patient is homebound because (i.e., "patient has shortness of breath with minimal exertion, requires numerous rest breaks for infrequent absences from home")
Face to Face Visit Attestation: I certify that this patient is under my care and that I, or a nurse practitioner/clinical nurse specialist/certified nurse-midwife or physician assistant working in collaboration with me or under my supervision, had a face-to-face visit encounter that meets the face-to-face encounter requirements with this patient.
Date of Face-to-Face Encounter
*
Physician Requesting Referral
Office Contact Name
Office Email