Referrals

Please submit the form below.  Referrals for home health services to SPCAA Home Health may be made by the patient, their physician or the physician’s staff, discharge planners, family members or friends. Upon receipt of this referral, SPCAA Home Health will verify the patient’s eligibility and appropriateness for home health services and will obtain orders from the treating physician prior to providing services.

Medicare pays 100% of the cost of home health services if the patient needs intermittent skilled nursing care or therapy, the service has been prescribed by the patient’s physician, and the patient is homebound. Qualifications for other payers varies.

If you have any questions or need any help completing this form please contact us at (806) 894 – 7872 or toll-free at (800) 687 – 2085.

 

Referral Contact Information

* denotes a required field

Your Name*

Your Email*

Your Relationship to Patient*

Your Phone Number*

Your Fax Number


Patient Contact Information

Patient Name*

Patient's Phone Number*

Patient's Date of Birth

Patient's Address

City

State

Zip


Physician Information

Physician's Name

Physician's Phone Number

Medicare Number

Medicaid Number

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