We are available to help you, your family, and your patients in any way possible. If you or someone
you know needs medical help in their home and you would like to know if you qualify for these benefits,
then please print the form below, complete and fax to 830-625-2194.
We appreciate your confidence in A & B Home Health Care, Inc. to provide you with personal and
professional care.
Thank you for your referral! Please print this page and complete then fax to 830-625-2194. We are a
Licensed and Certified Home Health Agency for the State of Texas.
Online Referrals
"WE CARE" A & B Home Health Care Inc.
A&B Home Health Care, Inc.
Fax: (830)-625-2194
Referral Form
|
* Patient: _______________________________________________ *Phone #1: _________________________
* Address: ______________________________________________ * Phone#2: _________________________
* City/State: ____________________________________ County: ____________________ ZIP: ________________
* DOB: _____________________ * SSN: ___________________________ ____ *Male ____ *Female
* ER Contact: _________________________________ * Relation: ________________ Phone: _________________
* Referral Source: ___________________________________________________ Phone: _____________________
* Referring Physician: _______________________________________________ *Phone: _____________________
* Address: _________________________________________________________ *FAX: _______________________
Physician ID UPIN#: _________________
PCP: ______________________________________________________________ Phone: _____________________
* Inpatient Facility: _________________________________________________ *Admit Date: ________________
* Anticipated DC Date: _________________________________ Anticipated Agency SOC: __________________
* Medical Condition/Diagnosis: ________________________________________________________________________
______________________________________________________________________________________________________
* Specific Orders: _____________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Comments: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
Continued on page 2
* Recent Surgical Procedure: ____________________________________________________________________________
* Primary Insurance: ________________________________ Secondary Insurance: ______________________________
* Medicare#: ___________________________ * Medicaid#: ___________________________
Private Insurance Co.: ___________________________________________________________________
Address: ___________________________________________________________________
Group#: __________________________ Contact Person: ___________________________________
Phone: ___________________________
* All Required Fields
