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Testimonials

I think Bob was able to get the most out of how he wanted to spend the remaining part of his life because of your help and the amazing Wendy, his caregiver. His remaining time without the help of your organization would have been completely different and we thank you very much for all that you did to allow Bob, a Navy veteran with an incredible independent spirit, live as he wanted to.
Joe R., Caregiver to neighbor
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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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