Doctors, Case Managers & Healthcare Facilities

How to make a referral? Confidence in care…

Doctors, Case Managers and Healthcare Facilities can be confident in the high level, quality care patients receive at Primary Medical Staffing, Inc. Please call us today at 305-819-2343 to make a referral.

Home care solutions at your fingertips.

Call us or fax your referral. Our intake department will confirm the plan of care you requested and gather information about the patient’s clinical status, demographics and source of payment. Authorization to implement the care plan will be confirmed – and you’re done!

When receiving a referral, we would like to know:

Patient information (name, address, phone number, date of birth, social security number, insurance information, emergency contact)
Name of primary care physician / referring physician
Diagnosis (current and history)
Current medications
Services requested
Treatment orders (i.e. wound care procedures, PT orders, Diabetic etc.)
Requested start of care
Mental status
Language spoken
Mobility status
Availability of backup caregiver, if necessary (name, phone number, capability, etc.) and willingness of caregiver to participate in care.

DOWNLOAD INTAKE FORM (HERE) – OR – COMPLETE FORM BELOW

14125 NW 80th AveSuite 205
Miami Lakes, Florida 33016

Home Health Care Services
Phone: 305-819-2343
Fax: 305-921-9096

Referral/ Intake Form

Date
Date Format: MM slash DD slash YYYY
Time

: HH

MM
Referred by
Demographic Information
Last Name:
First/ Midlle:
Medical Record #:
Medicare:
Medicaid:
Insurance:
Social Security:
DOB:
Language:
Address:
Phone:
Emergency Contact
- Next to Kin
- Referred Hospital/ Agency
- Clinical Team Nurse/ Social Worker/Other
- Name:
- Relationship:
- Address:
- Phone:
- Name:
- Ph#:
- Fax:
- Adm Dx:
- Name:
- Ph#:
- Ext:
- Pager:
- Fax
Attending Physician
- Name:
- Address:
- Ph#:
- UPIN#:
- Date:
  Date Format: MM slash DD slash YYYY
Services required
- Wound Care:
- Type Location:
- Home Health Dx:
- Diabetic
- Home Bound _ Endurance ; Devices Other
Attach Dr’s Order and Patient past medical history
Signature
Date
Date Format: MM slash DD slash YYYY

REFERRER:

Your Name

Your Organization

Tel. No.

CONTACT PERSON:

Contact's First Name

Last Name

Tel. No.

PATIENT'S INFO:

Patient's First Name

Patient's Last Name

Tel. No.

Patient's Address

Insurance Information

Patient's Date of Birth

Day

Year

Patient's Medicare Number

Has the patient ever received home health care service in the past?

Patient lives in a

Is the patient able to drive a car safely on a regular basis?

Does the patient use any type of assistive device e.g. cane, walker, wheelchair?

Is the patient willing to receive home health services?

CALL NOW
305-819-2343

How to make a referral? Confidence in care…

Home care solutions at your fingertips.

When receiving a referral, we would like to know:

14125 NW 80th AveSuite 205
Miami Lakes, Florida 33016

Home Health Care Services
Phone: 305-819-2343
Fax: 305-921-9096

Referral/ Intake Form

Demographic Information

Next to Kin

Referred Hospital/ Agency

Clinical Team Nurse/ Social Worker/Other

Attending Physician

Services required

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How to make a referral? Confidence in care…

Home care solutions at your fingertips.

When receiving a referral, we would like to know:

14125 NW 80th AveSuite 205 Miami Lakes, Florida 33016

Home Health Care Services Phone: 305-819-2343 Fax: 305-921-9096

Referral/ Intake Form

Demographic Information

Next to Kin

Referred Hospital/ Agency

Clinical Team Nurse/ Social Worker/Other

Attending Physician

Services required

14125 NW 80th AveSuite 205
Miami Lakes, Florida 33016

Home Health Care Services
Phone: 305-819-2343
Fax: 305-921-9096