Referral Guide

General Information (needed for all referrals)

Current Demographics:

  • Name
  • Address (including county)
  • Current phone number
  • Date of birth
  • Drug allergies
  • Gender
  • Language spoken
  • Height
  • Secondary phone number
  • Social Security number
  • Weight

Insurance Information:

  • Employer name
  • Insurance company
  • Insurance ID and group number (if known)
  • Previous AHC patient
  • Policy holder
  • Policy holder date of birth (if policy holder and patient are not the same)

Ordering Physician:

  • Diagnosis
  • Emergency contact/ next of kin/ care giver
  • Primary physician (if not the same as ordering physician)

Type of Service or Equipment: (May require qualifying diagnosis)

  • Home Medical Equipment (HME: walkers, canes, wheel chairs, etc.)
  • Home Health (Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Work, Home Health Aide)
  • Infusion / Specialty Pharmacy
  • Respiratory (Oxygen , aerosol, CPAP, BiPAP, nebulizer, ventilator)

Bookmark with:

Delicious     Digg     reddit     Facebook     StumbleUpon
print this pagePrint this page        email a link to this article to a friendE-mail this to a friend