Referring Patients for Home Care, Hospice, or Home Infusion Therapy
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FAX Referrals |
Telephone Referrals |
Discharge Orders |
Guidelines for Coverage of Home Care Services |
Physician Responsibilities |
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FAX Referrals
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Fax Referral Form (PDF file)
Click on the link above to see and print a Fax Referral Form. To do so, you need to have Adobe Acrobat Reader installed on your computer. If you do not already have Acrobat Reader installed, click below.
Download Adobe Acrobat Reader to your computer.
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Telephone Referrals
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Call 1-800-557-9777
Fax 510-547-3257 or 1-800-596-5444
Please provide the following information:
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Patient's Name
Patient's Phone Number
Patient's Date of Birth
Patient's Social Security Number
Emergency Contact Person
Allergies
Last MD Office Visit
Homebound Status
Doctor's Name
Doctor's Phone Number
Diagnosis: Current and Other Significant Medical Data
For Hospice: Estimated prognosis of six months or less; please call to discuss eligibility.
Specific Orders for Care (Note: services cannot be exclusively for the purposes of phlebotomy.)
Insurance Carrier, Phone Number, and Policy Number
Name of Policy Holder
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Discharge Orders
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Please refer to us by name on the hospital discharge orders. Ask for Sutter VNA & Hospice for home care, hospice care, or home infusion therapy.
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Guidelines for Coverage of Home Care Services
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The patient is homebound due to medical reasons. (Medicare requirement.)
The patients requries the skilled services of a registered nurse, physical therapist, and/or speech language pathologist.
The patient and/or caregiver is willing and able to participate in the plan of care.
Skilled services are part-time and intermittent.
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Physician Responsibilities
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Sign Orders: Home Health Certification and Plan of Care. A HCFA 485 for Medicare and a Sutter VNA & Hospice form for other payers fulfill this purpose. Physician signature is required on this form within 30 days of the start of care. These incorporate intial orders and clinical assessment. This is required to meet regulartory requirements and for reimbursement.
Change in Plan of Care: A document that contains previously obtained verbal orders for change in care. Physician signature is required within 30 days of verbal order.
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