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THAGroup.org

eReferral

* Required field

If you have any questions regarding your referral please call 888.THA.HOME

Referred By:
*Full Name	*Email Address	Phone Number
*Primary Physician's Name	Phone Number
Referring Physician's Name	Phone Number

*Referred To:
	Home Care Island Health Care		Hospice Care Island Hospice		Private Home Care Independent Life at Home

Patient Information:
*First Name	*Last		Middle
Address			*Phone
City	State	Zip	County (if known)
	GA SC
Date of Birth (mm/dd/yyyy)	SSN
*Who Should We Call to Arrange Services?	Relationship to Patient		Phone
Is an Interpreter Needed? Yes No

Insurance/Payor Source
Primary	Policy Number
Secondary	Policy Number

History & Physical
Will you complete this section online or fax the information to THA Group? Online Fax to 888.THA.FAX3

*Orders
Will you complete this section online or fax the information to THA Group? Online Fax to 888.THA.FAX3

Nursing	Speech Therapy
Physical Therapy	Social Work
Occupational Therapy	Private Duty Aide

Infusion Therapy/Enterals
Will you complete this section online or fax the information to THA Group? Online Fax to 888.THA.FAX3

Do you have a preferred infusion company?			Do you have a preferred DME company?
No Yes, if yes			No Yes, if yes
Access Device
Peripheral	Central	Midline	Date device inserted? (mm/dd/yyyy)
Epidural	Other
Infusion Medications		Dose	Frequency	Duration	First Dose?
					Yes No
					Yes No
					Yes No
					Yes No
IV/TPN Fluids		Rate	Duration
Enteral Solution		Rate	Duration

Additional Notes (if any)