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Home
The Girling Difference
Our Caregivers
Our Hiring Process
Home Care Services
By Service
Personal Care
Rehabilitative Care
Physical Therapy
Speech Therapy
Occupational Therapy
Specialized Care
Specialty Programs
Diabetes Home Care Program
Balance and Fall Prevention
Pulmonary Health Program
Orthopedic Home Care Program
Heart Healthy Program
Nursing Services
Social Services
By Condition
Alzheimer’s Disease
Diabetes Care
Heart Disease
Parkinson’s Disease
Stroke Care
Pulmonary Disease (COPD)
By Life Event
Adult Senior Care
Post-Surgical Care
Chronic Care
Remote Monitoring
Affiliated Companies
HCS Home Care Services Of NY
Direct Care
AJ Home Care-An HCS Company
Careers/Jobs
Contact Us
Home Care Referral Form
Intake Dept.
Direct: (718) 748-7447
Fax: (718) 748-5191
IntakeCE@GirlingNY.com
Marketer
Marketer Name
No Marketer
Patient Name
Sex
Male
Female
Date Of Birth
Email
Message
Address
Phone
City
Zip Code
Language
Medicare
Medicaid / Other
Social Security
Social Security
Allergies
Emergency Contact
Phone
Physician Name
Phone
Fax
1. Certification and Date of Face-to-Face Encounter
I certify that this patient is under my care and that I, or a nurse practitioner, clinical nurse specialist or physician's assistant workingwith me, had a face-to-face encounter with this patient on:
2. Medical Condition Related to Home Health Services
The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for homehealth care:
3. Certification of Medical Necessity
I certify that based on my clinical findings the following services are medically necessary for home care services (fill in all that apply)
Skilled Nursing for:
Physical Therapy for:
Other:
4. Certification of Homebound Status
My clinical findings from this encounter support the patient is homebound due to:
Leaving home requires a considerable and taxing effort
Absence from home are infrequent, of short duration or to receive healthcare treatment
Medically restricted due to immunosuppression, infectious illness, risk of infection or injury
Licensed Agency Vendor Request
If the patient is determined to need home health aide services, I am requesting that the CHHA use the following Licensed Agency Vendor:
Physician Name:
Date:
NPI:
License Number:
Address:
Submit Referral