Refer a Patient
Access a variety of information resources and tools to help you successfully refer a patient for home healthcare services.
Refer a Patient to Home Healthcare Services
Advanced Clinical Associates (ACA) strives to help physicians and other healthcare providers connect their patients with the home healthcare services they need to live and recover safely at home. This page offers several tools and information resources to help you successfully refer a patient into ACA’s care.
How to Refer a Patient
If your patient needs home healthcare services and meet the Eligibility Requirements, use the tools below to complete a referral.
- Download Patient Referral Form: This downloadable form includes ACA’s Face-to-Face Progress Note, Home Health Orders and a fax cover sheet. After completing this form and the Required Referral Information (outlined below) fax to:480-477-6571.
- NOTE: Please call 602-373-0540 to verify all faxed documents were received.
Online Referral Tools: Participating providers can submit referrals electronically through Curaspan eDischarge/Navihealth and ECIN (Allscripts Care Management).
Required Referral Information
The information and documentation listed below must be included with all home healthcare referrals submitted to Advanced Clinical Associates.
- Type of referral (i.e., start-of-care for a new patient or a resumption of care?)
- Demographic sheet to include:
- Patient’s first and last name
- Address – This should be the location where the patient will receive homecare services. It may differ from the patients mailing address or home address.
- Phone number
- Email address
- Insurance information
- Emergency contact information
- Patient’s primary language
- Patient-selected representative or power of attorney
- Face-to-Face requirement documentation: The Centers for Medicare and Medicaid Services (CMS) require that a physician have a face-to-face encounter with a patient to certify him/her for home care.
- Physician’s homecare order (if face-to-face encounter documentation not required)
- Referring physician’s name and phone number
- Physician’s name and phone number who will be following the patient for homecare services
- Medication profile
- Hospital transfer/discharge summary and date (if applicable)
- Patient’s history and physical
Home Infusion Referral Requirements
In addition to the items listed above, the following information is also needed for infusion referrals:
- Current labs
- Signed physician’s order with medication, dose, frequency and duration (NOTE: A nurse’s verbal orders are not acceptable)
- PICC line X-ray including indicated tip placement and length of PICC line
- Lab/blood work orders (if applicable) and the physician who should receive the results
Home Healthcare & Infusion Referral Fax
- Services Available: Learn more about ACA’s specialized home healthcare services.
- Service Area Map: View a map that illustrates the areas where Advanced Clinical Associates provides care across Maricopa County.
- Payment Options: Learn more about the payment options for services offered by Advanced Clinical Associates.
- What to Expect from Home Healthcare: Gain better understanding and knowledge of how ACA’s medical experts help patients heal in the comfort of home.
Patient Referral Forms
For your convenience, you may download and print ACA’S Patient Referral Forms here. To ensure timely initiation of care please fax these completed forms and other required documentation to (480) 477-6571 and call (602) 373-0540 to confirm receipt.