Contact us - Client referrals | Fidelity Care Home Health | Contact information, address, telephone number

Four ways to reach us

e-mail, online form links

CONTACTING US IS EASY AND FAST.

For Referrals: Please click here

Telephone: 281-550-0053

FAX: 281-550-3150

E-Mail: info@FidelityCareHH.com

Website: http://www.FidelityCareHH.com

Office Address: 16100 Cairnway, Ste 295, Houston, TX 77084

EMERGENCY INFO

In the event of a medical emergency whether at home or elsewhere, please call 911 immediately.

Physicians, Hospitals & individual Referrals

If you are a private Physician, a Hospital Rep., or individual who needs special care or follow-up for a loved one, you may refer your patients to us. Please click appropriate link below and fill out the form.

Physician Referral

Hospital Referral
Private Individual Referral

REFERRAL FROM A PRIVATE PHYSICIAN

                                                      Patient's Information                  *Required Fields

Title: Mr. Mrs. Ms

*First Name :

*Last Name :

Medicare :    ID# Group#

Medicaid :    ID# Group#

Private Ins.   ID# Group#

DOB :    Year:

*Street Address :

*City :

*State :

*Zip Code :

*Phone :

Email Address :

             Physician's Information            *Required Fields

*Title:

*Physician's Name :

*Phone :

Email Address :

Does Patient Need an Interpreter?

No   / Yes    Language:

Patient Diagnosis :

Procedure :

Discharge Date :

EVALUATIONS:

Diabetes Home Care

Heart Home Care

Occupational Therapy

Private Duty Aide

Physical Therapy

Rehab Home Care

Skilled nursing

Social Work

Speech Therapy

Patient's Medical History:
(Comments & specifications)

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REFERRAL FROM A HOSPITAL

                                                     Patient's Information                     *Required Fields

Title: Mr. Mrs. Ms

*First Name :

*Last Name :

Medicare :    ID# Group#

Medicaid :    ID# Group#

Private Ins.   ID# Group#

DOB :    Year:

*Street Address :

*City :

*State :

*Zip Code :

*Phone :

Email Address :

        Hospital Information   *Required Fields

*Hospital's Name :

*Attending Physician's Name :

*Attending Physician's Phone :

Case Manager's Name:
(In case we cannot reach Physician)

Case Manager's Phone:

Case Manager's Title: RN BFN MS

Does Patient Need an Interpreter?

No   / Yes    Language:

Patient Diagnosis :

Procedure :

Discharge Date :

EVALUATIONS:

Diabetes Home Care

Heart Home Care

Occupational Therapy

Private Duty Aide

Physical Therapy

Rehab Home Care

Skilled nursing

Social Work

Speech Therapy

Patient's Medical History:
(Comments & specifications)

Back to the top

REFERRAL FROM A PRIVATE INDIVIDUAL

                                                    Patient's Information                    *Required Fields

Title: Mr. Mrs. Ms

*First Name :

*Last Name :

Medicare :    ID# Group#

Medicaid :    ID# Group#

Private Ins.   ID# Group#

DOB :       Year:

*Street Address :

*City :

*State :

*Zip Code :

*Phone :

Email Address :

       Referrer's Information       *Required Fields

*Your First Name :

*Your Last Name :

*Home Phone :

Cell Phone :

Email Address :

*Street Address :

*City :

*State :

*Zip Code :

Your Relation to the Patient?

Does Patient Need an Interpreter?

No   / Yes    Language:

Patient Diagnosis :

Procedure :

Discharge Date :

Patient's Medical History:
(Comments & specifications)

Location: 16100 Cairnway, Suite 295 Houston, TX 77084

Office Hours: 9:00 AM - 5:00 PM (Monday-Friday)

Visit us online: http://www.FidelityCarehh.com

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