University of Michigan Home Care Services Referral Form

  • Home Infusion Pharmacy
  • Infusion Services
  • Nutrition Therapy
  • Specialty Drug Therapies
  • FAX Number: 734-975-3079
  • Medical Equipment
  • Medical Supplies
  • Respiratory Services
  • FAX Number: 734-971-1004
Michigan Visiting Nurses
  • Nursing Services
  • Therapy (OT, ST, PT, MSW)
  • Home Health Aide (Personal Care)
  • Private Duty
  • FAX Number: 734-975-3088
Michigan House Calls
  • Home Primary Care
  • FAX Number: 734-998-2369

Patient Information
CPI number: Date of Birth: (mm/dd/yyyy)  
First Name:   M.I.    Patient's phone:
Last Name: Alternate Contact:
Address for Care: Alternate Phone:
City:   State:   ZIP:   Relationship to Patient:
Primary Insurance: Desired Start Date:  OR
Current Diagnosis: Orders/Services Needed: Disciplines Requested:

Physician Information   
Ordering Physician   Following Physician for Home Care Orders
First Name:  M.I.    First Name:  M.I.  
Last Name: Last Name:
Phone #  Pager # Phone # Pager #
Facility/Clinic Name: Facility/Clinic Name:

Contact Person's Name: Phone Number: E-mail Address: