Univita Form PDF Details

The Univita Referral Form serves as a critical tool in the healthcare industry, streamlining the process of referring patients for various services. Spanning over two pages, this document is meticulously designed to capture essential information about a patient, including personal details, health plan, insurance type, and contact information. It goes further to inquire about the patient's primary and secondary diagnoses, diabetes status, and the need for medical equipment at home, thereby offering a comprehensive overview necessary for facilitating personalized care. In addition, the form asks for details on the referring physician, the primary care provider, and any nursing or pharmacy orders, ensuring that all medical needs are communicated effectively. Specific sections are dedicated to the type of services required, such as evaluations for home or wound care needs, physical therapy, and HT evaluation and treatment. The form also includes a section for physician attestation, signifying the accuracy and medical necessity of the orders. The careful construction of this form, last updated in early 2012, reflects a keen awareness of the importance of confidentiality and compliance with HIPAA regulations, emphasizing the secure handling of personal health information. This document not only facilitates efficient communication between healthcare providers but also underscores the commitment to patient privacy and the meticulous adherence to legal standards.

QuestionAnswer
Form NameUnivita Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesUnivita Universal Referral Form 02012012 univita form

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Page 1 of 2

UNIVITA REFERRAL FORM

PATIENT REFERRAL INFORMATION

 

Patient’s First Name:

Patient’s Last Name:

 

 

 

 

 

 

Member#:

DOB:

 

 

 

 

 

 

 

Health Plan:

Insurance Type:

 

 

 

 

 

 

Primary Phone Number:

Secondary Phone Number:

 

 

 

 

Home Address:

City, State & Zip Code:

 

 

 

 

 

Service Address:

Service City, State & Zip Code:

 

 

 

 

Alternate Contact Name:

Primary Phone Number:

 

 

 

 

Relationship to Patient:

Secondary Phone Number:

 

 

 

 

Primary Diagnosis & Code:

Secondary Diagnosis & Code:

 

 

 

 

 

Date of Discharge:

Facility Name:

 

 

 

 

 

 

 

Diabetic? □ No □ Yes Type: □ IDDM □ PO □

HT:

 

WT:

Diet

 

 

 

 

 

 

 

 

 

Allergies:

 

 

 

 

 

 

 

 

Are services medically necessary for home health care?

□ Yes

□ No

PCP -Name of MD:

 

Phone Number:

 

 

 

Fax Number:

 

 

Following MD (if other than PCP):

 

Phone Number:

 

 

 

Fax Number:

 

 

Referrals’ name:

 

Referrals’ contact number:

 

 

Referral Fax Number:

NURSING ORDERS:

 

 

 

 

 

 

 

 

 

Nurse Evaluation – Evaluate for home or wound care needs & treatment

Wound care treatment plan & Location: ________________________________________________

__________________________________________________________________________________

Physical Therapy Evaluation & Treatment

HT Evaluation & Treatment ‐ home infusion/ medication(All first doses need to be given at the facility or PCP office)

Administration ‐Medication, dosage, route & frequency/ duration: ___________________________

__________________________________________________________________________________

Other:_________________________________________________________________________

FAX REFERRAL TO: 888-914-2202

Last Update: 02/01/2012

Univita Referral Form

Notice ‐The documents accompanying this telecopy transmission from Univita Health may be confidential and / or privileged. The information is intended only for the use of the individual or entity named on this transmission sheet. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or any action taken based on the contents of this telecopies information is STRICTLY PROHIBITED and could be a violation of HIPAA and the Privacy Rule (Public Law 104‐191, enacted on August 21, 1996). The documents must be returned to this office immediately. If you have received this telecopy in error, please notify us by telephone so that we can arrange for the return of the original document(s) to us at no cost to you. Privacy Officer – (tel) 954‐334‐1945 (fax) 952‐983‐5107.

(MM/ DD/ YYYY)

Page 2 of 2

UNIVITA REFERRAL FORM

PHARMACY ORDERS:

Medications (including medication name, dose, route, frequency, and duration):

Lab Orders (as appropriate):

IV Access:Number of Lumens:

DME ORDERS:

HCPC Code

Description

Length of Need

NOTE: For Oxygen Orders, please provide:

Liter Flow per Minute

Route: Nasal Cannula, simple mask or other

Date of last patient encounter: (MM/ DD/ YYYY)

Hours of use: continuous, with exertion, hours of sleep, bleed into CPAP/BiPAP or other

Delivery Device: concentrator, portable cylinders, conserving device, liquid Helios portable, or other

Date of saturation test:

Oxygen Saturation or PO2 results:

%

****Attach all history & physical, discharge plans, any surgical reports, treatment and

medication list***

SECTION C Physician Attestation and Signature/Date

I certify that I am the treating physician identified in this form. I have received the Certificate of Medical Necessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability.

PHYSICIAN’S SIGNATURE ______________________________________________________________________ DATE _____/_____/_____

PHYSICIAN’S NAME (Please print):________________________________________________________________

Signature and Date Stamps Are Not Acceptable

Last Update: 02/01/2012

FAX REFERRAL TO: 888-914-2202

Univita Referral Form

Notice ‐The documents accompanying this telecopy transmission from Univita Health may be confidential and / or privileged. The information is intended only for the use of the individual or entity named on this transmission sheet. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or any action taken based on the contents of this telecopies information is STRICTLY PROHIBITED and could be a violation of HIPAA and the Privacy Rule (Public Law 104‐191, enacted on August 21, 1996). The documents must be returned to this office immediately. If you have received this telecopy in error, please notify us by telephone so that we can arrange for the return of the original document(s) to us at no cost to you. Privacy Officer – (tel) 954‐334‐1945 (fax) 952‐983‐5107.

How to Edit Univita Form Online for Free

Working with PDF files online is actually a breeze using our PDF editor. Anyone can fill in Univita Form here painlessly. The editor is constantly maintained by our team, acquiring useful features and turning out to be greater. Here's what you will have to do to get going:

Step 1: Click on the orange "Get Form" button above. It's going to open our pdf editor so you can begin completing your form.

Step 2: As you open the PDF editor, you will find the document prepared to be completed. Other than filling out different blank fields, you might also do some other things with the Document, namely adding any text, modifying the initial text, adding images, placing your signature to the PDF, and more.

It is actually straightforward to fill out the form following our detailed tutorial! Here's what you should do:

1. Start completing the Univita Form with a selection of major fields. Consider all the information you need and be sure absolutely nothing is forgotten!

Univita Form completion process outlined (part 1)

2. The third stage would be to complete all of the following fields: Diabetic No Yes Type IDDM PO, Phone Number Fax Number Phone, Referrals name, NURSING ORDERS Nurse Evaluation, FAX REFERRAL TO, and Last Update Univita Referral Form.

A way to complete Univita Form part 2

3. The following section should be quite simple, PHARMACY ORDERS Medications, Length of Need, NOTE For Oxygen Orders please, Liter Flow per Minute, Route Nasal Cannula simple mask or, Date of last patient encounter MM, and Hours of use continuous with - these fields is required to be filled in here.

Route Nasal Cannula simple mask or, NOTE For Oxygen Orders please, and Liter Flow per Minute of Univita Form

It is possible to make errors while completing the Route Nasal Cannula simple mask or, and so you'll want to take a second look before you decide to submit it.

4. The next paragraph will require your information in the following areas: Hours of use continuous with, Oxygen Saturation or PO results, Attach all history physical, medication list, SECTION C Physician Attestation, I certify that I am the treating, FAX REFERRAL TO, and Last Update Univita Referral Form. Make sure that you give all of the needed information to move onward.

Part number 4 for completing Univita Form

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