top of page

REFER TO RELIEF

At Relief, we aim to make our referral process as easy as possible. Anyone can make a referral, and we work directly with the patient's provider to create an appropriate care plan based on our nurses' assessment. 

​

If you have any questions about the referral process, please call us and ask to speak with our Intake Department. 

​

As a tool, we've also put together a resource where you can check to see if we take a particular insurance plan. Click here to find out, and don't hesitate to reach out if you have any questions. 

Relief Home Health Services Referral Form

Birthday
Month
Day
Year
Gender

Patient Mailing Address

Multi-line address
Healthcare Proxy Invoked?
Yes
No

Insurance

Primary Insurance

Patient's Relationship to Policy Holder:
Self
Parent/Guardian
Partner/Spouse
Other

Secondary Insurance

Patient's Relationship to Policy Holder:
Self
Parent/Guardian
Partner/Spouse
Other

Physician/Practitioner

F2F Encounter Date:
Month
Day
Year
F2F Encounter Requests Home Care:
Yes
No

Referral Information

Does the Patient Have a History of Violence?
Yes
No
Does the patient's diagnosis support the need for Home Health Services?
Yes
No
Eval and Treat (Check All That Apply):
Referral Source has Ordered Wound Care Supplies
Yes
No
Specific Start of Care Date (If Applicable):
Month
Day
Year
Is Patient Homebound?
Yes
No
Are All Elements of Homebound Status Present?
Yes
No

Admission/Referral Source

Institution Type:
LTC
SNF
IPPS
LTCH
IRF
Psychiatric Unit
Patient had an acute or post-acute stay in the last 14 days.
Community
Other

Additional Information:

For a complete referral you must upload the below information using the file upload or FAX TO: 800-508-0614

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date and time
Month
Day
Year
Time
HoursMinutes

If you'd prefer to fax your referral, please download the PDF version of our referral form.

bottom of page