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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*
Date Format: MM slash DD slash YYYY
SSN*
Insurance Carrier Name*
Carrier ID Number*
Carrier Group Number
Start of care must be within 48 hours unless otherwise noted by physician.
Diagnosis
Specific Orders
Physician name*
Physician phone number*
Family contact name
Phone
Face 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*
Date Format: MM slash DD slash YYYY
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 field
Help

Refer A Patient
Home Care Needs Assessment
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