Testimonials

I take care of both my parents and haven't had a day off in almost 4 years. The respite five hours a week is such a blessing. It gives me time to run errands and if I have time left over, I take myself out to lunch or go to a park and read a book. Those five hours are a gift of time that I never had.

Teri D., Caregiver

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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:

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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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