Referral form

Please provide the necessary information below for your client referral who is to receive HealtheMed’s “Clinic@Home” digital support system.

(i.e. Home and Community Based Services)

This form is HIPAA Compliant. Call 952-562-1235 with any questions.

NPI# 1881253037
FAX: 844-999-1534
Email: referrals@healthemed.com

We will let you know the referral was received and then work to get the services approved and/or coordinate shipping and remote setup. When the device is shipped or notifications have been set up we will follow up with you again to let you know. Thank you for the referral!

Referral

I am a *

First Name* Last Name* Phone Number * Email * Organization

Waiver Case Manager / Waiver Case Coordinator Information

First Name Last Name Phone Number Email Organization

Client Information

Please provide the necessary information below for your client referral who is to receive HealtheMed’s “Clinic@Home” digital support system.

Client First Name* Client Last Name* Date of Birth (mm-dd-yyyy) * Phone Number* Email* PMI / Member / Subscriber ID # Waiver Categories*
Street Address* City* State/Region/Province* Postal / Zip Code* County

Caregiver

Who should we contact to set up Services?

This will be the person we contact to help arrange the delivery and setup of our Services.

What else would you like us to know?
How did you hear about us? *

We will contact you to confirm the referral was received.
We will contact the person responsible for approval/filling medications to confirm services/setup.
We will follow up with you after everything is set up. Thank you for the referral!