Make A Referral Liberty HomeCare & Hospice Services appreciates our valued relationships with other medical professionals. If you would like to make a referral to Liberty, please fill out the form below: This form is for physician referrals only – if you are a patient or family member, please fill out the contact us now form. Referral contact name*Referral Email Physician Email* Note: this field must be the physician's email address for completion of the Face-to-Face e-signature.Phone*What kind of referral do you need?* Home care Hospice Patient information: Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*DOB* SSN*Insurance Carrier Name*Carrier ID Number*Carrier Group NumberStart of care must be within 48 hours unless otherwise noted by physician.DiagnosisSpecific OrdersPhysician name*Physician phone number*Family contact namePhoneFace to Face is required for Medicare and NC Medicaid.I certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me, had a face-to-face encounter that meets the physician face-to-face encounter requirements with this patient on* The encounter with the patient was in whole, or in part, for the following medical condition, which is the primary reason for home healthcare (List medical condition; primary and secondary diagnosis):*I certify that, based on my findings, the following services are medically necessary home health services (Check all that apply)* Nursing Physical Therapy Speech Language Pathology My clinical findings support the need for the above services because:*Additional services ordered: Occupational Therapy Medical Social Work Home Health Aide Skilled Nursing Physical Therapy Speech Therapy Documentation to Support Homebound Status is Only Required for Medicare Patients. (Skip this section if the patient is covered by NC Medicaid.)Further, I certify that my clinical findings support that this patient is homebound (i.e. absences from home require considerable and taxing effort and are for medical reasons or religious services or infrequently or of short duration when for other reasons) because:* = This is a required fieldHelp This iframe contains the logic required to handle Ajax powered Gravity Forms.