Physician Referral Portal

Create a Patient Referral

Submit your MD Order / Referral Form directly to Premier One Home Care. Our intake team reviews every submission within 1 business day.

Secure SubmissionPDF Delivered to Intake1 Business Day Response

📋 MD Order / Referral Form

Premier One Home Care, LLC · 931 E Southern Ave, Suite 212 · 480-773-6837

MD Office Information

Referring physician or practice details

MD Office Name & Address*

Office Address

Phone*

Fax

Patient Information

Details about the patient being referred

Patient Name*

Patient Address*

Phone*

Date of Birth*

Insurance Information

Insurance #1 Policy #

Insurance #2 Policy #

Diagnosis

ICD-10 codes or clinical diagnosis descriptions

Diagnosis Primary*

Diagnosis Other

Services Ordered

Select all services required for this patient

Skilled Nursing

HH RN — Medication management, safety eval, disease management and education, any other services necessary

Wound Care Instructions

Advanced wound care including wound VAC therapy as indicated

PT: Eval & Treat

Physical therapy evaluation and treatment

OT: Eval & Treat

Occupational therapy evaluation and treatment

Speech Therapy: Eval & Treat

Medical speech-language pathology evaluation and treatment

Medical Social Work

Psychosocial assessment, care coordination, resource referral

Home Health Aide

Personal care, hygiene, and daily living assistance

Other Orders

Provider Information

Referring provider details — digital submission serves as electronic signature confirmation

Provider Name*

NPI #*

Date*

Electronic Signature Notice: By submitting this form, the referring provider confirms the accuracy of this referral and authorizes Premier One Home Care to initiate home health services as indicated above.

Submitter Contact

Who is submitting this referral? (office staff, physician, or family)

Your Name

Your Email*

Your Phone

Your referral is delivered as a PDF directly to our intake inbox. For urgent referrals, call 480-773-6837 or fax to 480-773-6854.

Need Help?

Call Intake

480-773-6837

Fax Referral

480-773-6854

[email protected]

Office Hours

Mon – Fri 8:00 AM – 5:00 PM

Sat – Sun

On-call 24/7 on-call support available for existing patients

Our Location

931 E Southern Ave, Suite 212, Mesa, AZ 85204

View on Map

What Happens Next?

Your referral is emailed as a PDF to our intake team

Our intake specialist reviews within 1 business day

We contact the patient and family to schedule assessment

A personalized care plan is developed with your physician

Care begins according to physician orders

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