Americare Home Health Care Services Florida

Doctors and Medical Professionals,

The AmeriCare Referral process is fast, easy and flexible! For your convenience we provide 5 ways for you to contact us so we can better serve you and your patients:

Call in a referral by calling your local AmeriCare office.
Fax in a prescription with an MD signature to your local AmeriCare office.
Print this fax referral form, complete it then fax it to your local AmeriCare office.
Contact your local Account Executive who will be happy to come assist you.
For the fastest service complete the secure online form below.

If faxing please attach the Patient's Demographic and a H&P or recent visit note - Thank You

Medical Professional Referrals Online

Referral Date: *

Patient Name: *

Contact Email: *

Patient SS #: *

Patient Medicare #:

Patient Birth Date: *

Patient Contact Information *

Street Address *


City *	State *	Zip *

Phone #: *

Patient Diagnosis and Services

Please list all relevant diagnoses:

Services Required:

Nursing

Physical Therapy

Occupational Therapy

Social Worker

Home Health Aide

Physician's Orders:

DME Needs:

Physician Digital Signature

Physician Name: *

Electronic Signature Statement: I acknowledge that inserting my name above represents my signature. (See Terms & Use)

NPI #: *

Signature Date:

February 22, 2012

Please Enter the Security Code Shown Below:

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4131 University Boulevard. #17 | Jacksonville, Florida 32216 - Phone: 904-722-1515 | Fax: 904-722-1517
771 Fentress Boulevard Suite 2F | Daytona Beach, Florida 32114 - Phone: 386-274-3199 | Fax: 386-274-3197