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

Please provide contact information for the person who will approve services if requesting through the Medicaid Waivers
First Name Last Name Phone Number Email Organization

HealtheMed “Clinic at Home” Telemedicine Platform

Price $15 per day or agreed upon County/State pricing

Client Information

Please provide information for the person who will be receiving the product. Client First Name * Client Last Name* Date of Birth (mm-dd-yyyy)* Phone Number Email PMI / Member / Subscriber ID # Waiver Categories * Address/Street Address * City State/Region/Province Postal / Zip Code County

Additional Information

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.

First Name Last Name Phone Number Email Additional Notes

What else would you like us to know about the Client or Referral?

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!