Testimonials

It makes me understand better what elderly people go through in their daily lives.

On the impact of the Caregiver Resource Center experience, Virtual Dementia Tour of Second Wind Dreams and P.K. Beville ®

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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:

Source Name:

Telephone:

Email:

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.