Online Patient Referral Form
Thank you for choosing Care Choice as your professional home health care provider. In order for us to serve you better, please provide us with the following information.
Please call 847-329-0648 ext. 10 if you would like to talk with someone on the phone.
Patient Information (* required)
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. Care Choice Home Health, Inc. and all its contractual providers are in full compliance with HIPAA requirements.
It is the policy of Care Choice Home Health, 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.