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It helped me to realize how much we take for granted on a daily basis, simple tasks that we don't even talk about. Not remembering all the instructions was upsetting.
On the impact of the Caregiver Resource Center experience, Virtual Dementia Tour of Second Wind Dreams and P.K. Beville ®
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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.

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