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Service Request
Service Request and Referral Form

Thank You for your interest in QCHC. A representative will contact you within 24hours. For further assistance you can contact us at 704-819-1378. Or Email us at Info@queencityhomecare.com.

Client First Name: Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits) State:
Primary Contact:
Relationship:
Phone:
Email:
Daytime Phone:  
Evening Phone:  
Lives Alone:
Referral Source:
MEDICAL INFORMATION
Primary Diagnosis:
Allergies:
Secondary Diagnosis:
Ambulatory:  Uses: Wheelchair  
Physicians Name: Physicans/Clinic Address:
Physicians Phone: Physicans Fax: 
BILLING SOURCE:
Medicaid#:
Medicare#:
Insurance Company:
Policy Holder:   
Policy #:
 Carolina Access:
Yes    No Location:
Private Pay: If Yes:
Self     other
qchc brochure..pdf

Enter the maximum amount you want to pay each month
$ USD
You can be billed up to $15.00USD
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