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The program was great! It came at a time when I was at my all-time lowest. The combination of the sessions with your counselors and the service to help my aunt was a tremendous help. They gave me what I needed at the right time. Words cannot explain how valuable United HomeCare was to me.
Dulce A., Caregiver on the impact of Community Reach II
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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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