Home Health and Hospice Referral

Complete our HIPAA-compliant Referral form below.

If you would prefer to download the form and send it to us, click here to download the form.

Submit your completed printable Home Health Referral Form by
— fax to: 1.866.642.5791
— or email to: ReferralsSentIntake@3HC.org

Referring Office/Contact Info

Referring Contact Name(Required)

First Last

Referrer Phone #(Required)

Referrer Email(Required)

Patient Info

Patient First Name(Required)

Patient Last Name(Required)

DOB(Required)

MM slash DD slash YYYY

Patient Address(Required)

Street Address City ZIP Code

Insurance(Required)

Diagnosis(Required)

Physician Signing 3HC Plan of Care

SERVICES ORDERED

Availability Varies By Location

Home Health

HOME HEALTH

check all that apply

Skilled Nursing

Aide

Wound Care

IV Medications

Hospice

(Not Available in Durham, Franklin, Granville, Vance, or Warren counties)

Patient Information Required for Referral Processing

Patient Profile
History
Physical (by MD, NP, or PA dated within 90 days of today with need for care indicated)
Medications
Primary Care Physician
Recent Facility Discharge Information (if applicable)

Comments

Our Intake Care Team will contact you as soon as possible to confirm the receipt of this referral. If you do not receive a call, please contact us at 1-800-692-4442.

Home Health and Hospice Referral

Referring Office/Contact Info

Patient Info

SERVICES ORDERED

Patient Information Required for Referral Processing

Patients & Families

Health Care Professionals

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