ONLINE PATIENT REFERRAL FORM
Thank you for choosing Applegate HomeCare & Hospice as your professional home care provider. For your convenience, we have provided an online physician referral form.
If you prefer to call, please call intake at 1-800-871-0102.
We respect your privacy. It is our responsibility to protect your personal and medical information.
Patients are informed of their rights to privacy of personal and medical information. Applegate HomeCare & Hospice, Inc. and all its contractual providers are in full compliance with HIPAA requirements.
It is the policy of Applegate HomeCare & Hospice, Inc. not to discriminate on the basis of race, color, national origin, language, sex, or religion in providing home health care services. We will not deny anybody with an infectious disease or disabilities.
We will not decline admission or limit services due to severity of medical condition; membership in or affiliation with a religious or fraternal group; location of services or facilities lacking handicap access. We will provide the necessary assistance to patients with sensory or speech impairments prior to obtaining consent for treatment.