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.