Referrals

Our online referral form allows you to send us basic patient information so that we can schedule for home health care services for the patient.

You can also call us at (586) 558-9112 or (866) 583-5433.

REFERRAL TYPE Doctor   Patient
 
PATIENT INFORMATION
 
First Name *
 Responsible Relative or Friend
Last Name *
 Relationship
Address
 Phone Number
City
 Hospital Admission
State
 Discharge Date
Phone Number *
  
Birth Date
  
Sex
  
Marital Status
  
 
INSURANCE INFORMATION
 
Hospital for Drugs or Supplies
 Blue Cross Number
Medicare Number
 Name of Subscriber
Medicaid Number
  
Other Insurance
  
Policy Number
  
 
OTHER INFORMATION
 
Note
 
REPORT BY PHYSICIAN
 
Visit to MD
 Date
Diagnosis
 Prognosis
Surgery Performed and Date
 Pt. Informed of Diagnosis
Complications
 Family Informed of Diagnosis
Rehabilitation Goal
 Brief Medical History
Medical Orders and Plan of Treatment
Nursing
Social Worker
Physical Therapy
Nutritionist		 Speech Therapy
Occupational Therapy
Home Health Aide
Current Medications
  
 
SIGNATURE *
 
 I certify that the above patient is under my care, requires the above Home Health Services and is confined to his(her) home. These professional services are to be provided on an intermittent basis and I will review the established plan at least every two months. These services are related to the diagnosis stated above the conditions for which he(she) received treatement while recently hospitalized.
Enter your full name as a valid signature *
Enter your email address to receive a copy of your referral
   
   
* - required fields
Skilled Nursing

Registered nurses provide case management, assessment, and treatment of the patient’s medical status.

Physical Therapy

Our therapists assist the patient with walking and exercises to improve mobility.

 Office Address & Hours

11885 E. 12 Mile Road Suite 100B
Warren, MI 48093

Mon - Fri, 9:00 am to 5:30 pm

 Phone

(586) 558-9112 / (866) 583-5433

 Fax

(586) 558-9113

 Email

inquiry@lifelinkhomehealthcare.com

Or send us a message through our Contact Form