Please complete the Home Health Referral Form by filling out all fields and clicking “Submit”.

To send a referral by fax:

Download our form below, complete it fully, then fax it to (713)977-1333


Use your own electronic order

Please include these requirements*:

1. F2F Encounter Date                                                              2. Demographics
3. Primary reason for home health care/diagnosis
4. My clinical findings support that this patient is homebound and meets the need for services
5. Skilled disciplines (eg, Skilled Nursing, PT, OT)

*If these requirements are not included on your referral, we will contact you to fill out this additional information; doctor’s signature required.