MAKE A REFERRAL

Information Required to Complete a Referral

Please obtain and provide the following information:

• Demographic:
  • Patient's name and address with apartment number, zip code, cross streets, and phone number.
  • Emergency contact, with home and work telephone numbers.
  • Patient's Date of Birth.
  • Patient's Social Security number.
  • Insurance information with the carrier's phone number and contact person to validate insurance and the name of the person who owns the policy. Include all authorization information from managed care carriers.
  • Physician's name, address, license and UPIN numbers of the physician who will sign the initial orders. The name and telephone number of any other physician who will provide care in the community.
• Medications the patient is currently taking and any known allergies.
• Diagnosis and prognosis: the anticipated outcome of treatment and skilled needs

For further assistance and or information please call or email Family Care Certified Services Intake department.