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Testimonials

Two years ago, I was sent to a nursing home and I spent more than a year there. I was depressed. I felt like I was distanced from society. Thanks to the agency, I am able to live in my apartment. The agency has really made a difference in my life. I feel like I have almost erased my depression.
Elsa S., Client

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:
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If other, specify:

Optional:

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

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