Focus Care Referral Form


24333 Southfield Rd. Ste. 200 Southfield MI, 48075 Tel. 800.430.0309/Fax:248.569.2148

Continuing Plan of Care

Patient Name(Last, First,Middle Initial)

Address for Care

Telephone No.

To Agency:	FocusCare Home Health 24333 Southfield Rd. Ste. 200 Southfield MI, 48075 Tel. 800.430.0309 Fax:248.569.2148
From

Patient's Address(if not same as above)

Telephone No.

Complete Date of birth

Sex

Male

Female

Referral Date

Reported By

Date of First visit

Reported To

Marital Status

Responsive Relative or Friend

Relationship

Telephone No.

Hospital Case No

Room No.

Admission Date

Discharge Date

Hospital for drugs & supplies
Medicare No.
Medicaid No.
PPOM No.
Name of Subscriber
Other Insurance
Policy No.

REPORTED BY PHYSICIAN

Diagnosis (List Primary First & Date of Onset)

Surgery Performed & Dates

Complications

Prognosis	Good	Fair
	Guarded	Poor
Patient Informed of diagnosis	Yes	No
Family Informed of Diagnosis	Yes	No

Rehabilitation

Brief Medical History

Visit to M.D.

Office

Clinic

Date of Visit

MEDICAL ORDERS AND PLAN OF TREATMENT

Diet

Activity

Medications Please: Check Meds. / Orders @ Home

Services Requested	Skilled Nursing	Social Worker
	Physical Therapist	Speech Therapist
	Occupational Therapist	HHAide

Durable Equipment Needed

Lab Draws

Ordered From (Company & Tel.)

I certify that the above patient is under my care, requires that the above Home Health Services, and is confined to his/her home. These professional services are to be provided in an intermittent basis and I will review the established plan atleast every two months. These servicves are related to the diagnosis stated above and conditions for which he/ she received treatment while recently hospitalized.

Physician Name

Addrerss

UPIN No.

Telephone No.

License No.

Date