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Home Health at Your Fingertips



How to make a referral

Physicians have three options for referring patients to the Baptist Health Louisville Home Health Agency: phone, fax and on-line.

Phone

- Call (502) 456-9988 24-hours a day, seven days a week, 365 days a year. Outside the Louisville metro area, call 1-800-248-0289.

Your call will be answered by qualified Home Health staff. If they are busy with another call, you can leave your information in the referral voice mailbox and you will receive a confirmation call within 30 minutes.

Information needed to make a referral includes: patient name, address and telephone number; birthdate; insurance numbers, if available; diagnosis; and orders for services.

Fax

- Complete fax referral form and transmit it to (502) 456-0668. Home health staff will call to confirm reciept.

On-line



Patient Information
* indicates a required field
  *First Name Middle *Last Name
*Patient Name
*Address
*City *State *Zip
*Patient Phone
Date of Birth
Name Contact Phone
Emergency Contact
Company Policy Number
Insurance
*Diagnosis
Surgery
*Allergies
Current Medications
Height Weight
Service Orders
Nursing
C/P Status Neuro/Vascular Status GI Status GU Status Endocrine
O2 Instruction L/min Maternal Newborn Phototherapy Mental Health
Dressing Change
Infusion Therapy/Enterals
Access Device: Peripheral        Central        Midline        Epidural        IVAD       
Medication Dose Frequency Duration Recieved in Past
1:
2:
3:
4:
IV Fluids TPN Rate Duration
1:
2:
3:
4:
Enterals Solution Amount Frequency
Lab Orders
Physical Therapy
Evaluation Theraputic Exercises Gait Training
Weight Bearing Status
Other
Establish Plan of Treatment
Occupational Therapy
Evaluation Muscle Re-Education ADLs
Other
Establish Plan of Treatment
Speech Language Pathology
Evaluation Dysphagia Therapy Speech and Language Therapy
Other
Establish Plan of Treatment
Home Health Aide
Personal Care
Medicaid Waiver Services
Social Services
Evaluation and Assist
Dietician Consult
Consultation
Additional Orders(include expected date of first visit)
Orders
Contact Information
*Full Name *Phone Number *Email Address
*Orders Completed By
*Full Name *Phone Number Email Address
*Referring Physician