Altimeters / Dementia

WE HAVE BEEN SERVING HOUSTON AND SURROUNDING COMMUNITIES SINCE 1996.

• Alvin
• Clearlake
• Conroe
• Dickinson
• Friendswood
• Galveston
• Houston
• Inner Loop
• Katy
• La Marque
• Magnolia
• Memorial
• Missouri City
• NASA
• Pasadena
• Stafford
• Sugar Land
• Texas City
• The Woodlands
• Tomball
• Webster

Patient Referral Information Form

Please complete this form for Patient Referral/Intake.

Patients First Name *

Patients Last Name *

SSN *

Sex *

Date Of Birth *

Month *

Day *

Year *

Patient Address

Street Address *

Suite / Apt # *

City *

State *

Zip Code *

Patient's Phone *

Nearest Relative / Emergency Contact

Contact Name *

Contact Phone *

Relationship *

Diagnosis Information 

Diagnosis *

Services Requested *

Skilled NursingPhysical TherapyOccupational TherapySpeech TherapyMSWHome Health AidePersonal Care Services

ICD-0 CM Codes *

Physician Information

Physican Name *

Phone *

Street Address *

Suite / Apt # *

City & State *

Payer Information

Primary Payer *Please select an option

Member ID# *

Payer Details

Phone

Case Management / Referral Contact

Referred By (Name) *

Phone *

Email Address

Facility Name *

Pertinent Notes

Send Message

Primary Home Care (PHC)*

Administered by Texas Department of Aging and Disability Services This is a non-technical program that provides attendants to assist with personal care such as bathing and grooming. Attendants will also do chores such as cleaning, laundry and meal preparation. A physician must certify that an individual’s medical condition warrants the need for these services.

Dynamic Home Health Services is Licensed and Certified by the State of Texas

• Medicare Parts A and B and HMO’s
• Medicaid and Medicaid HMO’s
• Pediatric CCP/MDCP Nursing and Therapy Programs

This program is a nontechnical, medically related personal care service provided to adults whose health problems cause them to be functionally limited in performing activities of daily living, according to a statement of medical need. PHC provider agencies also provide Family Care services. This service also is a non-skilled, nontechnical service provided to eligible clients who are functionally limited in performing daily activities.

Covered Services:

Escort: Attendants accompanying clients on trips to obtain medical diagnosis, treatment, or both. This service does not include the direct transportation of the client by the attendant.

Home Management: Assistance with housekeeping activities that support the client’s health and safety, including:

• changing bed linens
• housekeeping
• laundering
• shopping
• storing purchased items
• washing dishes

Personal Care: Assistance with activities related to the care of the client’s physical health, including:

• bathing
• dressing
• grooming
• routine hair and skin care
• preparing meals
• feeding
• exercising
• helping with self-administered medication
• toileting
• transferring/ambulating