Legacy Home Health Care

4500 Legacy Drive
Suite 100
Plano, TX 75204
Telephone: 972-781-0242
Fax: 972-781-0234
Email: info@legacymedhealth.com

We welcome the opportunity to help you, a member of your family, and your patients. Your comments, suggestions and requests are welcome as well. The entire staff of Legacy Home Health Care appreciates your confidence in allowing us to provide you with personal and professional home health care services tailored to meet your individual needs.

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Preview Information

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Other, please describe:
Have you previously received home care services? If so, when?
Please provide as much information as possible about your home care needs so we can respond quickly to your inquiry:

Referrer's Information (person sending referral)

First Name:
Last Name:
Phone Number: (xxx) xxx-xxxx
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Referral's Information (person being referred)

Patient's Name:
Street Address:
Address (2nd):
City:
State:
Zip Code: [5 digits]
Work Phone: (xxx) xxx-xxxx
Home Phone: (xxx) xxx-xxxx
Date of Birth:
Insurance Carrier:
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Medicare Number:
Physician's Name:
Physician's Phone: (xxx) xxx-xxxx
What types of services are required?

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