Make a Referral | Ultimate Bliss Services Home Health

1

Referral Source Information

Tell us about yourself so we can follow up with you directly

Who is making this referral?

Physician / Provider

MD, DO, NP, PA ordering home health services

Discharge Planner / Case Manager

Hospital, SNF, or insurance case manager

Family Member / Caregiver

Requesting care on behalf of a patient

Self-Referral

Requesting care for myself

Other

Social worker, community organization, etc.

Please select who is making this referral.

Your Contact Information

First Name *

Last Name *

Title / Role

Organization / Facility

Phone *

Email *

Best time to reach you

2

Patient Information

Basic demographics for the patient requiring home health services

Patient Demographics

Patient First Name *

Patient Last Name *

Date of Birth *

Gender

Preferred Language

Phone Number *

Alternate Phone

Home Address / City *

Caregiver / Emergency Contact

Caregiver / Contact Name

Relationship

Caregiver Phone

Lives Alone?

Desired Start of Care

3

Clinical Information

Diagnosis, services requested, and relevant medical history

Diagnosis & Physician

Primary Diagnosis *

ICD-10 Code (if known)

Secondary Diagnosis

ICD-10 Code

Ordering Physician *

Physician Phone

Physician Fax

Services Requested

Please select at least one service.

Homebound Status & Functional Information

Homebound Reason

Functional Status

Known Allergies

Additional Clinical Notes

4

Insurance & Payment Information

We will verify benefits before starting services — no surprises

Primary Insurance

Insurance Type *

Insurance Company (if other)

Member / Policy ID

Group Number

Date of Birth (for verification)

Secondary Insurance (if applicable)

Secondary Insurance

Member / Policy ID

Urgency & Additional Info

Referral Urgency

Discharge Date (if applicable)

How did you hear about us?

Any other information

HIPAA Notice: The information submitted through this form is protected health information (PHI) and will be used solely for the purpose of coordinating home health services. Ultimate Bliss Services complies with all HIPAA privacy regulations. By submitting this form, you consent to our use and disclosure of PHI as permitted under HIPAA for treatment, payment, and healthcare operations.

5

Review & Submit Referral

Please review all information before submitting

What happens next? Once submitted, our team will contact you within 24 hours to confirm receipt and discuss the patient's needs. We will contact the patient or family within 48 hours to schedule the initial RN assessment.

Online Patient Referral

Referral Submitted!