HNL @Home - Homebound

Only healthcare providers can schedule appointments for medically homebound patients. Please contact your healthcare provider to schedule your appointment.

Schedule an appointment for your medically homebound patients. For clients that currently order Homebound services through Epic (or another EMR system), the online form serves as an additional option, not a replacement.

Date of Visit

Please enter a specific date or a date range. Example: “Any day next week.” Next day requests cannot be honored.

Patient Information - Please fill out Patient Information Section

Patient First Name

Patient Last Name

Date of Birth

Gender

Street Address 1

Street Address 2

City

State/ Province

Postal Zip Code

Phone Number

Upload/Scan Order

Please select a file

Please scan/upload the order. Please write “Patient is medically homebound” on the order. Order must have provider signature to be valid.

Upload Additional Supporting File

Please select a file

Physician Information - Please fill out patient information section

Physician First Name

Physician Last Name

Name of Practice

Client Number

Street Address 1

Street Address 2

City

State/ Province

Postal / Zip Code

Phone Number

NPI No.

Special Instructions/Requests

Duplicate Report to

Physician’s Name

Physician’s phone number

Patient Billing / Insurance Information

Please fill in patient billing / insurance information

Billing Insurance Information

reCAPTCHA

News and Stories

Everything You Need to Know About HIV Testing

Unveiling the World of Genetic Counseling: An Interview with Elizabeth Melchionna

Gut Check: Clostridium difficile

Celebrating Our Commitment to Quality: Recent CAP Inspection Validates HNL Lab Medicine’s Excellence

World Stroke Day

HNL @Home - Homebound