Testimonials

The program has helped me to survive and cope with my severe depressions and to help me cope with everyday problems that come with the depression. It gives me a better quality of life.

Denise D., Client, on the impact of Healthy IDEAS

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Customer
Care Center

Community Service Referral

Please fill in the form below. In order to fax or mail, please print this form and return it to:

United HomeCare
Customer Care Center
8400 N.W. 33rd Street, Suite 400
Miami, FL 33122
Email: customercare@unitedhomecare.com
Fax: (305) 639-3093

Or call us at (305) 716‐0710 and a representative will help you complete this form over the telephone.

Date of Referral:

Referred by:

Source Name:

Telephone:

Email:

Client Information:

Name:

Date of Birth:

Sex:

Female Male

Contact Phone:

Contact Email:

Caregiver Info (if applicable):

Contact:

Relationship:

Preferred Language:

Spanish English Creole Other

If other, specify:

Optional:

Physician Name:

Telephone:

Medicare Referral: If skill services are needed, please submit Physician Order and Fact Sheet.

Comments:

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