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Home Health & Hospice Care Referral Form Referring Office/Contact Name: ___Referring Phone #: ___Patient Name: ___DOB: ___Patient Address: ___ Insurance: ___Diagnosis: ___Physician Signing 3HC Plan
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Gather all necessary medical information and paperwork.
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Contact a home health or hospice agency to schedule an assessment.
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Meet with a healthcare professional to discuss care needs and develop a plan of care.
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Follow the instructions provided by the agency for medication management, wound care, therapy, and other services.
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Keep track of any changes in health status and communicate with the healthcare team as needed.
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Individuals with chronic or terminal illnesses who require ongoing medical care and support.
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Patients who have difficulty leaving their home or are unable to care for themselves independently.
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Families who need assistance in caring for a loved one with complex medical needs.
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Home health and hospice care is a service that provides medical treatment, support, and comfort to individuals who are ill, disabled, or terminally ill in their own homes.
Healthcare providers, facilities, or organizations that provide home health and hospice services are required to file this information.
Home health and hospice information can be filled out electronically through the appropriate reporting system or software provided by the relevant health authorities.
The purpose of home health and hospice is to ensure that individuals receive necessary medical care and support in the comfort of their own homes.
Information such as patient demographics, medical diagnoses, treatment plans, services provided, and outcomes must be reported on home health and hospice.
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