CONTACT US or call: (305) 716-0710

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

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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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