Online Referrals
Online Referrals
E-Referral
Referral Information
NOTE: Fields labeled with bold text are required.
Referrer Information
Physician UPIN
Physician Name
Physician Telephone
Physician Fax
Physician Email
Referral Source
(Person filling out form)
Referrer Phone
Referrer Email
 
Patient Information
Name
Street Address
City, State ZIP ,
Telephone
eg. 603.555.1212
Date of Birth (Month) (Day) (Year)
Gender M F
Marital Status
Social Security #
(for the purpose of checking benefits)		 --
Allergies
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Street Address
Emergency Contact City, State ZIP ,
Emergency Contact Telephone
eg. 603.555.1212
 
Patient currently at Home Nursing Home Hospital
Family/Friend's Other

Reason for referral:
 
Disciplines being requested: Nurse PT OT ST MSW Aide Meals On Wheels Adult Day Care Hospice PD HMK
Diagnosis
Specific Orders/Additional Information
Primary Care Physicican Name
Primary Care Physician phone
Primary Care Physician fax
 
Primary Payor source Medicare Medicaid Commercial Insurance
Self-pay Other (specify)
Primary Insurance ID #
Primary Insurance Company Name
Primary Insurance Company Phone
 
Secondary Payor source Medicare Medicaid Commercial Insurance
Self-pay Other (specify)
Secondary Insurance ID #
Secondary Insurance Company Name
Secondary Insurance Company Phone
Please fax supporting documentation, if available, to 603.881.8995. (History & Physical, medication list, latest notes, etc.)

Home Healthcare, Hospice and Community Services (HCS) is Medicare certified, and licensed by the State of New Hampshire. HCS programs are provided to all service eligible individuals without regard to age, race, religion, sex, handicapping conditions, marital or economic status, except where constrained by specialized funding. HCS is a United Way Agency.