Referrals

Personal Care Inc. accepts referrals from physicians, attorneys, case managers, social workers, nurses, clergy, and family members who believe that someone can benefit from assistance in their home. Each referral will receive a free confidential screening to determine if the person is appropriate for our services.

There are a number of advantages to working with our company to provide home care.

  1. We provide a holistic assessment of the situation that takes into account both the medical needs of the client and the emotional needs of both the client and the client’s family. Our care plans are developed in conjunction with clients and the family to ensure that everyone’s concerns are addressed. We also make sure that physicians are fully informed regarding their patients.
  2. We pre-screen our employees with criminal background and reference checks, as well as providing additional training opportunities for them.
  3. We are available 24 hours a day, 7 days a week should an emergency arise. And we always work to find a substitute should an employee have to be out of work, so that clients do not miss the services that they need.
  4. When problems arise we quickly work with clients and family members to resolve them. As a locally owned company clients receive individual attention and quick responses to their needs. We specialize in keeping family members who are out of town informed and up-to-date on the status of their loved one.

No other company can match our holistic combination of experience, comprehensive services, qualified staff, and sincere compassion.

Your Name:


Your Email:


Patient Email:


Patient Date of Birth(mm/dd/yy):


Patient Address:


Patient Phone #(xxx-xxx-xxxx):


Patient E-mail Address:


Family Contact:


Family Phone #(xxx-xxx-xxxx):


Physician Name:


I authorize in home aid service for my patient.
Yes No

Physician Phone #(xxx-xxx-xxxx):


Physician E-mail Address:


Assessment

1) Patient is medically stable in a private residence.
Yes No

2) Patient needs assistance with personal care tasks in the residence due to his/her medical condition. (May range from total care to fall prevention while patient provides self-care)
Yes No

3) Patient/Family unable/unwilling to meet all personal care needs without assistance.
Yes No

4) Does the patient need assistance managing the home, or with appointments, errands, or taking medications?
Yes No

If you answer yes to the above questions, Personal Care is an appropriate referral. Complete form and submit.

What are the medical diagnoses for this patient?

Medicaid Number:

Access #:

Diagnosis & ICD 9 #1:

Diagnosis & ICD 9 #2:

Diagnosis & ICD 9 #3:

Diagnosis & ICD 9 #4:

Diagnosis & ICD 9 #5:

Diagnosis & ICD 9 #6:


Functional Limitations:
Bed bound

Wheel chair

Walker

Transfers


Other Functional Limitations:


Additional Comments:




Referral Inquiries: referral@personalcareinc.com


Personal Care Inc.
1 Centerview Drive
Rockingham Building, Suite 202
Greensboro, NC 27407
(800) 927-0716, (336) 274-9200
(336) 274-4083 (fax)
info@personalcareinc.com

Serving the greater Triad area: Greensboro, Winston-Salem, High Point
Serving the following counties: Guilford, Alamance, Rockingham, Forsyth, Davidson, Randolph

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