Physician & Agency Referrals

Complete Your Referral Form

Fill out the Face-to-Face certification, sign digitally, download your PDF, and fax to intake at (682) 200-7472.

← Back to Referrals · Download blank PDF instead

How it works: Fill out each section below, sign as the certifying physician, then download your PDF and fax it to intake. Include physician orders and supporting documentation with your fax.

Referring Practitioner / Facility

Included on the downloaded PDF for intake follow-up.

Practitioner Name / Clinic *

Referring NPI *

Contact Name / Title *

Callback Phone *

Contact Email *

Patient Information

Patient Full Name *

Date of Birth *

Face-to-Face Encounter Date *

Face-to-Face Certification

I certify that a Face-to-Face encounter was performed on the above-named patient.

Medical condition(s) — primary reason for home health *

Homebound due to *

Services ordered (check all that apply) *

Skilled Nursing Wound Care Physical Therapy Occupational Therapy Speech Therapy Home Health Aide Diabetic Care & Education Chronic Disease Management

Physician Signature (Texas — physician must sign)

Print Name *

Certifying physician — printed on the signature line of your PDF.

Signature Date *

Draw signature below *

I attest that the information provided is accurate, the Face-to-Face encounter occurred as documented, and I am the signing physician authorized to certify this referral under Texas and CMS requirements (42 C.F.R. §424.22).

Encounter date must be within 90 days prior to home health start, or within 30 days after start. A non-physician practitioner may perform the encounter, but only a physician may sign this document in Texas.

Ready to send your referral? Preview your form, download the PDF, then fax to (682) 200-7472 with orders and clinical attachments.