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Why Doctors Refer AdvanCare
Why Doctors Refer AdvanCare
AdvanCareGivers
Home Health
Refer us
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AdvanCareGivers
Home Health
Referral Form
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For medical professionals and other's convenience, we have prepared the online home health care referral form that allows you to refer your clients directly.
Rest assured that the information you submit via online home health care referral form will be kept secured and confidential. Your referrals will be treated with the utmost professionalism by our staff.
Copyright 2012 AdvanCare Health Services LLC - All Rights Reserved
AdvanCare Healthcare Services, LLC
Abbrievated Privacy Policy: AdvanCare Healthcare Services, LLC and all its employees recognize the importance of protecting all your personal, health and financial information, you, our online visitor or client provides to us. This online policy is a commitment to ensure the safe transmittal of all information from hackers, viruses, and any and all perpetrators.
We protect your Personal Health Information from inappropriate use or disclosure. Our employees are required to comply with our requirements that protect the confidentiality of your Personal Health Information. They may look at your Personal Health Information only when there is an appropriate reason to do so, such as to administer our products or services.
We will not disclose your Personal Health Information to any other company for their use in marketing their products to you. However, as described below, we will use and disclose Personal Health Information about you for business purposes relating to your Health Insurance coverage.
The main reasons for which we may use and may disclose your Personal Health Information are to evaluate and process any requests for coverage and claims for benefits you may make or in connection with other health-related benefits or services that may be of interest to you.
Disclaimer: The medical information transmitted through online forms, via email and fax are confidential and protected by both State and Federal Law. It is unlawful for unauthorized persons to review, copy, disclose, or disseminate confidential medical information from and through the AdvanCare Health Services, LLC website. If in error, you receive information which you are not the intended recipient of, please notify us immediately through phone or email and delete the document you have received or return the original document to AdvanCare Health Services, LLC via mail.
Referral Form
Retirement
Community
Referral Form
Please click referral type below:
Please verify (you) the referer's contact information
Email Address *
Your Name*
Your Organization*
Tel. No.*
Fax No.
RETIREMENT COMMUNITY
CLIENT INFORMATION:
Client's Last Name*
Client's First Name*
Client's Tel. No.*
Contact Person
Contact Person's Tel. No.
Clients Address*
Email
Billing Information
Client's Medicare Number
Client's Date of Birth
Has the client ever received home health
care service in the past?
Client lives in a
Is the client able to drive a car
safely on a regular basis?
Does the client use any type of assistive
device e.g. cane, walker, wheelchair?
Is the client willing to receive
home health services?
Please click the submit button when you have
completed the fields
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Call (708) 392-2000
Abbrievated Privacy Policy: AdvanCare Healthcare Services, LLC and all its employees recognize the importance of protecting all your personal, health and financial information, you, our online visitor or client provides to us. This online policy is a commitment to ensure the safe transmittal of all information from hackers, viruses, and any and all perpetrators.
We protect your Personal Health Information from inappropriate use or disclosure. Our employees are required to comply with our requirements that protect the confidentiality of your Personal Health Information. They may look at your Personal Health Information only when there is an appropriate reason to do so, such as to administer our products or services.
We will not disclose your Personal Health Information to any other company for their use in marketing their products to you. However, as described below, we will use and disclose Personal Health Information about you for business purposes relating to your Health Insurance coverage.
The main reasons for which we may use and may disclose your Personal Health Information are to evaluate and process any requests for coverage and claims for benefits you may make or in connection with other health-related benefits or services that may be of interest to you.
Disclaimer: The medical information transmitted through online forms, via email and fax are confidential and protected by both State and Federal Law. It is unlawful for unauthorized persons to review, copy, disclose, or disseminate confidential medical information from and through the AdvanCare Health Services, LLC website. If in error, you receive information which you are not the intended recipient of, please notify us immediately through phone or email and delete the document you have received or return the original document to AdvanCare Health Services, LLC via mail.
