Primex Healthcare Services Inc.

PRIMEX REFERRAL & PHYSICIAN ORDER FORM

SECTION 1 — PATIENT INFORMATION

SECTION 2 — INSURANCE / PAYOR INFORMATION

SECTION 3 — REFERRING PROVIDER INFORMATION

SECTION 4 — SERVICES REQUESTED

Skilled Nursing Services.

Home Health Aide Services

SECTION 5 — DIAGNOSIS & ICD-10 CODES

SECTION 6 — PHYSICIAN ORDERS / PLAN OF CARE

SECTION 7 — ATTACHMENTS (Check all that apply)

SECTION 9 — PHYSICIAN CERTIFICATION

I certify that I am referring this patient for home health services and that this referral form serves as the official physician’s order in compliance with Medicare Conditions of Participation (42 CFR §484.60) and Title 22 California Code of Regulations

SECTION 9 — FOR PRIMEX INTERNAL USE ONLY