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Physician's referral Form
Watermark at Home accepts referrals 24 hrs a day 7 days a week. Please see our areas of coverage.
If you are ready to request our services, please:
1. Download and print the Physician Order for Home Health Services Form (pdf, 400kb)
2. Select the Home Health services requested
3. Have the ordering physician sign. (Please note: per Federal Law, home health orders must be signed by a MD or DO.)
Then Fax the following items to Watermark at Home, Intake Department at 520-886-1900.
1. The signed Physician Order Form
2. Patient Demographic information
3. Patient Insurance information (include authorization if applicable, see note below)
4. History and Physical or most recent visit note
5. Current Medication list
A Watermark at Home Intake team member will call your office to let you know that we have received your request for referral and provide you with a date of when the patient will be seen.
AUTHORIZATION NOTE: Watermark at Home will obtain authorization for home health services, EXCEPT HEALTHNET. HealthNet requires the authorization to be obtained by the referral source before treatment begins. To obtain HealthNet Authorization for your patients contact HealthNet at 1-800-977-7518. Once obtained, please send the authorization number, number of visits per discipline authorized, the begin date and the expiration date of the authorization.
5830 N. Fountains Avenue | Tucson, AZ 85704 | Phone: 520-886-4400 | Fax: 520-290-1900