Testimonials

Telehealth has kept me balanced and has saved us from many unnecessary ER/hospitalization visits. It's not just a machine, it is the ability to speak with a nurse, which is my life line.

Surama O. & Alva C., clients

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Customer
Care Center

Community Service Referral

Please fill in the form below. In order to fax or mail, please print this form and return it to:

United HomeCare
Customer Care Center
8400 N.W. 33rd Street, Suite 400
Miami, FL 33122
Email: customercare@unitedhomecare.com
Fax: (305) 639-3093

Or call us at (305) 716‐0710 and a representative will help you complete this form over the telephone.

Date of Referral:

Referred by:

Source Name:

Telephone:

Email:

Client Information:

Name:

Date of Birth:

Sex:

Female Male

Contact Phone:

Contact Email:

Caregiver Info (if applicable):

Contact:

Relationship:

Preferred Language:

Spanish English Creole Other

If other, specify:

Optional:

Physician Name:

Telephone:

Medicare Referral: If skill services are needed, please submit Physician Order and Fact Sheet.

Comments:

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