For Home Hemodialysis Patients

Please download our Admissions Checklist below. The information included in this checklist is needed to process your requested admission.

Fax to: 281-565-0817

*This information is secured according to HIPAA standards and requirements.

Universal Dialysis, LLC is licensed by the Department of Aging and Disability, the founding company of Universal Home Therapy. We provide Home Health Care and Home Hemodialysis with a staff-assisted RN/LVN.

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Admissions Checklist (PDF)

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Other Diagnosis

Patient's Emergency Contact *

Patient's Type of Insurance *

Emergency Contact's Phone *

Primary Holder's Employer

Services Requested *

Patient Hospitalized? *

Yes

If Yes, where?

Case Manager's Phone

Patient's Name *

Patient's Phone *

Patient's Diagnosis *

Patient's Date of Birth *

Patient's SSN

Patient's Address *

Physician's Name: *

Physician's Fax *

Physician's Phone *

INTAKE REFERRAL FORM

Please complete this Intake Referral Form for your patient. Fields marked with a red asterisk(*) are mandatory & require a complete submission. When finished, click the SUBMIT button & our Intake Referral Coordinator will contact you within 24 hours.

UniversalHomeTherapy

Universal Home Therapy

12919 Southwest Freeway #138 Stafford, TX 77477 US

Phone: 281-565-1277 Website: http://www.universalhometherapy.com/

Policy Number *

Group *

Insurance Phone *

Primary Holder's Name

Case Manager's Name