Contact Us – Home Health Referral Form

Let us know how VitalCaring can help you or a loved one. Call 1.844.337.6813 or fill out the form below and we’ll be in touch soon. We kindly request that you refrain from including any patient details in this form.

VitalCaring Home Health Referral Form

Patient Information

Name(Required)

First Last

MI:

SSN:(Required)

Medicare #:(Required)

Health Plan #:(Required)

DOB:(Required)

Address:(Required)

City/State:(Required)

Zip:(Required)

Phone:(Required)

Emergency Contact:(Required)

Phone:(Required)

*Please provide H/P and visit notes from most recent office visit.

Referral Checklist

Face-to-Face Encounter Note Attached, Supports need for Home Health and Medical Necessity, Supports Homebound Status, Occurred Within 90 Days Prior to SOC

H&P, D/C Summary or MD Visit Note, Document must relate to primary reason for HH

Copy of Demographics Attached

Ordering MD

Phone

PCP (if different than ordering MD):

Focus of Care

Diagnosis:

Specific Orders:

Nursing

HHA

MSW

Evaluate & Admit:

Protocols

Ortho (Type):

Heart Failure

General Surgery

Pain

Other

Licensed Practitioners Name:(Required)

NPI:(Required)

Signature

Date(Required)

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To contact our Human Resources team, please call 844.654.1274.
Patients and Providers
If you are a patient or provider and need assistance, please call 1.844.337.6813.