Schedule: Monday - Friday 9:00am - 5:00pm, On Call 24/7

Patient Referral Application

We work on a referral basis. Though referrals typically originate with the physician, they may also originate form local hospitals, doctor’s office, board and care or skilled nursing facility and also, from the patient’s family, other interested persons or agencies. Complete the from below to refer a patient to LA Best Home Health Care.

*denotes required fields


PATIENT INFORMATION

First Name*

Last Name*

Date of Birth*

Address*

City*

State*

Zip*

Phone*

Medicare No.*

Other Insurance*

Policy No.*

Group No.*

Emergency Contact Name*

Emergency Contact Phone*

Relationship to Patient*

Hospitalized During Last 2 Weeks*
Yes No 

Diagnosis*

Surgery or Procedure (if any)*

Date of Surgery/Procedure

Hospital Discharge Date



PHYSICIAN ORDERS

Services Ordered*
SN PT OT ST MSW HHA 

Laboratory Test Orders*

Test Results To (Physician's Name)*

Phone*

Fax*

Other Patient Needs/Physician Orders*


We respect your privacy. It is our responsibility to protect your personal and medical information.

Privacy Statement:
Patients are informed of their rights to privacy of personal and medical information. LA Best Home Health Care, Inc. and all its contractual providers are in full compliance with HIPAA requirements.

PATIENT REFERRAL FORM

We work on a referral basis. Though referrals typically originate with the physician, they may also originate form local hospitals, doctor’s office, board and care or skilled nursing facility and also, from the patient’s family, other interested persons or agencies. Complete the from to refer a patient.