Remedial Patient Care - Secure Referral Form

Remedial Patients Care | Website Referral Form

Step 1: Patient Information

Patient First Name*

Patient Last Name*

Patient Phone*

Please confirm patient phone number to prevent delays.

Address*

Perferred Language*

Gender*

Male

Female

Type of Visit*

Home Visit (Physical)

TeleHealth

Patient D.O.B*

Step 2: Insurance Information

Medicare Part B, Insurance #

Reason for Visit Request*

Please select your preferred MD (Medical Director) to sign the referral*

You're now able to select MD in order streamline your paperwork

MOHAMMAD SIDDIQUI | NPI: 1356963185

RAFAEL PENUNURI | NPI: 1831270362

MICHAEL K. WENSLEY, MD | NPI: 1841336740

Additional Comments

Step 3: Preferred Facility

If we have worked together in the past you may just fill the facility name, phone, & contact name.

Name of Facility*

Address

Contact Person*

Phone Number*

Please make sure phone number is correct.

Read Terms of Service*

Purpose of Request (CMS-Specific) This request is made solely to obtain an independent face-to-face medical evaluation in accordance with 42 CFR §424.22(a) to determine whether the Medicare beneficiary meets Medicare coverage criteria for home health services, including medical necessity, homebound status (42 CFR §409.42), and need for intermittent skilled services (42 CFR §409.44). No certification or Plan of Care is implied by this request.  Clinical Independence Statement The evaluating provider shall perform a personally conducted face-to-face encounter, exercise independent medical judgment, and certify services only if Medicare criteria are met. The provider is not required to certify home health services.  Fraud & Abuse Compliance Attestation No payment, remuneration, incentive, or referral obligation exists or is offered in connection with this request, in compliance with the Anti-Kickback Statute, Stark Law, False Claims Act, and applicable California law.  Patient Freedom of Choice Acknowledgment The Medicare beneficiary has been informed of their right to choose any qualified provider or home health agency.  Billing & Documentation Responsibility The evaluating provider may bill Medicare directly for covered services. The home health agency will not prepare or modify clinical documentation. I acknowledge that checking the box below constitutes my legal electronic signature and agreement to these terms.

I Agree that I have read and consent to the terms of service above