Healthcare Solutions – Homecare & Nursing Referral / Intake Form

Please complete all required fields before submitting.

Referring Physician Information

Physician Full Name *

Practice / Facility Name *

Phone Number *

Fax Number

Date of Referral *

Email Address *

Patient Demographics

First Name *

Last Name *

Date of Birth *

Gender

Phone *

Alternate Phone

Preferred Language

Home Address *

Emergency Contact Name

Emergency Contact Phone

Diagnosis & Medical History

Primary Diagnosis *

ICD-10 Code *

Secondary Diagnosis / Comorbidities

Recent Hospitalization / Surgery

Current Medications & Dosages

Known Allergies

Code Status

Functional Limitations / ADL Status

Clinical Notes / Special Instructions

Services Requested *

Home Nursing Care

Skilled RN/LPN visits, medication management, vital monitoring

Post Hospital Care

Recovery support, ADL assistance, transitional care after discharge

Wound Care

Dressing changes, wound assessment, debridement support

Urology Care

Catheter management, urological nursing support & education

Other

Please describe the service required below

Frequency / Duration of Visits

Requested Start Date

Additional Notes on Services Required

Urgency of Referral *

Routine Urgent — within 48 hrs STAT — same day

Insurance & Authorization

Primary Insurance Carrier *

Policy / Member ID *

Group Number

Insurance Phone

Physician Attestation & Signature

I hereby certify that the above-named patient is under my care and that the requested homecare and nursing services are medically necessary. All information provided is accurate and complete to the best of my knowledge. I authorize Healthcare Solutions to initiate the outlined services and bill the indicated insurance accordingly.

Physician Printed Name *

Date Signed *

Electronic Signature — Type full name to confirm *

Credentials / Title

All information is handled in accordance with HIPAA regulations.
For urgent or STAT referrals, please also call our intake team directly after submitting.

Referral Submitted

Thank you. Our intake team at Healthcare Solutions will review this referral and contact the referring physician within 1 business day.

For urgent or STAT matters, please call our intake line directly.

Referral Submitted

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