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Home Health at Your Fingertips

Physicians can make an on-line referral to Central Baptist Hospital Home Care by filling out the form below.

Telephone Referral

Physicians can refer patients to Central Baptist Hospital Home Care 24 hours a day by calling (859) 260-6569 or toll free outside the Lexington metro area 1-800-489-3002. Your call will be answered by qualified home health staff. If our staff is busy with another call, you can leave your information in the referral voice mailbox and you will receive a confirmation call within 30 minutes.

Information needed to make a referral includes:

patient name, address and telephone number;
birthdate;
insurance numbers, if available;
diagnosis; and
orders for services.

Online Referral:

Patient Information

* indicates a required field

	*First Name	Middle	*Last Name
*Patient Name
*Address
	*City	*State	*Zip

*Patient Phone
Date of Birth
	Name		Contact Phone
Emergency Contact
	Company		Policy Number
Insurance
*Diagnosis
Surgery
*Allergies
Current Medications
Height		Weight

Service Orders

Nursing
	C/P Status	Neuro/Vascular Status	GI Status	GU Status	Endocrine
	O2 Instruction L/min	Maternal Newborn	Phototherapy	Mental Health
Dressing Change

Infusion Therapy/Enterals
Access Device:	Peripheral	Central	Midline	Epidural	IVAD

	Medication	Dose	Frequency	Duration	Recieved in Past
1:
2:
3:
4:

	IV Fluids	TPN	Rate	Duration
1:
2:
3:
4:

Enterals Solution	Amount	Frequency

Lab Orders
Physical Therapy
	Evaluation	Theraputic Exercises	Gait Training
	Weight Bearing Status
Other
	Establish Plan of Treatment
Occupational Therapy
	Evaluation	Muscle Re-Education	ADLs
Other
	Establish Plan of Treatment
Speech Language Pathology
	Evaluation	Dysphagia Therapy	Speech and Language Therapy
Other
	Establish Plan of Treatment
Home Health Aide
	Personal Care
	Medicaid Waiver Services
Social Services
	Evaluation and Assist
Dietician Consult
	Consultation
Additional Orders(include expected date of first visit)
Orders

Contact Information
	*Full Name	*Phone Number	*Email Address
*Orders Completed By
	*Full Name	*Phone Number	Email Address
*Referring Physician