Physician Referral Form

1 Referring professional

Physician / NP / PA Hospital discharge planner Social worker / case manager Skilled nursing / rehab facility Family member

Referring provider name

Practice / facility

NPI number (optional)

Phone

Fax

2 Patient information

First name

Last name

Date of birth

ZIP code

Patient / family phone

Insurance type

Requested start of care

Primary diagnosis / reason for referral (ICD-10 or description)

3 Services needed — check all that apply

Skilled Nursing Physical Therapy Occupational Therapy Speech Therapy Medical Social Work Home Health Aide IV Therapy Wound Care

Urgency: Routine (48–72 h) Urgent (same day) Emergency — call intake now: (407) 875-1801

Additional clinical notes — discharge date, special instructions, equipment needs, wound description, language needs

4 Certifying physician (if different from referring provider)

Certifying physician name

NPI

Fax

Face-to-face encounter: CMS requires a qualifying encounter within 90 days before or 30 days after start of care. Kassy Health will request the F2F documentation directly — families are never asked to chase it.

Referring provider signature

Date