Book a House Call Appointment - Essen Health Care

Form Instructions

Thank you for your referral and/or service request. Please allow up to 48 hours for our team to respond.

This is a secure site and all information obtained will be used to contact and schedule your patient.

All fields marked with * are mandatory. Please provide complete information for accurate referral processing.

Service Request

Type of Care Request *

Select the type of care request from the list above.

Where did you hear about us? *

Select how you heard about Essen Health Care.

Person Filling Out the Form

First Name *Example: John

Last Name *Example: Smith

Phone Number *

Format: XXX-XXX-XXXX (example: 212-555-1234)

Email Address *Example: john.smith@example.com

Relationship to Patient *

Select your relationship to the patient.

Referring Partner Agency Name *Enter the agency name, or "NA" if not applicable.

Patient Information

Patient's First Name *Example: John

Patient's Last Name *Example: Smith

Patient Phone Number *

Format: XXX-XXX-XXXX (example: 212-555-1234)

Alternative Phone Number (Optional)

Format: XXX-XXX-XXXX (optional, example: 718-555-5678)

Email (Optional)Example: john.smith@example.com (optional)

Date of Birth *

Format: MM/DD/YYYY (example: 03/15/1980)

Address

Street Name *Enter the full street address.

Apartment/Suite Number (Optional)Optional: apartment or suite number.

City / Borough *Enter city or borough name.

State / Province *Example: New York

Zip Code *

Format: 5-digit zip code (example: 10001)

Insurance Information

Does patient have Medicare? *

Select Yes or No.

Does patient have Medicaid? *

Select Yes or No.

Primary Insurance Name *

Select the primary insurance provider.

Primary Insurance ID Number *Enter the insurance ID number from the patient's card.

Secondary Insurance Name (Optional)

Optional: Select secondary insurance if applicable.

Secondary Insurance ID Number (Optional)Optional: Secondary insurance ID number if applicable.

Additional Patient Information

Additional Information (Optional)Optional: Provide any additional information relevant to the referral.

Discharged from Hospital/Nursing Home in Past 6 Months? *

Select Yes or No.

Document Attachments

Optional: Upload up to 5 supporting documents (PDF, DOC, DOCX, TIF). Maximum 5 MB per file.

Attachment 1 (Optional)Supported formats: PDF, DOC, DOCX, TIF

Attachment 2 (Optional)Supported formats: PDF, DOC, DOCX, TIF

Attachment 3 (Optional)Supported formats: PDF, DOC, DOCX, TIF

Attachment 4 (Optional)Supported formats: PDF, DOC, DOCX, TIF

Attachment 5 (Optional)Supported formats: PDF, DOC, DOCX, TIF

Refer New Patient

Form Instructions

Service Request

Person Filling Out the Form

Patient Information

Address

Insurance Information

Additional Patient Information

Document Attachments