{"id":3157,"date":"2020-05-23T21:53:17","date_gmt":"2020-05-23T21:53:17","guid":{"rendered":"https:\/\/www.angelscarehealth.com\/?page_id=3157"},"modified":"2023-04-30T00:00:11","modified_gmt":"2023-04-30T00:00:11","slug":"phy-npp-referral-form","status":"publish","type":"page","link":"https:\/\/www.angelscarehealth.com\/phy-npp-referral-form\/","title":{"rendered":"PHY\/NPP Referral Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"3157\" class=\"elementor elementor-3157\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-17ba9fa elementor-section-content-top elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"17ba9fa\" data-element_type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-9cbfadb\" data-id=\"9cbfadb\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e701105 elementor-widget elementor-widget-text-editor\" data-id=\"e701105\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\tPlease fill out the form and attach any supporting documents (History and Physical, Diagnostic Tests, and Labs) to be submitted.\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-09666c2 fluent-form-widget-step-header-yes fluent-form-widget-step-progressbar-yes fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"09666c2\" data-element_type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_5 ffs_default_wrap'><form data-form_id=\"5\" id=\"fluentform_5\" class=\"frm-fluent-form fluent_form_5 ff-el-form-top ff_form_instance_5_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_5_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">PHY \/ NPP referral Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='3157' \/><input type=\"hidden\" id=\"_fluentform_5_fluentformnonce\" name=\"_fluentform_5_fluentformnonce\" value=\"207b998f18\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/3157\" \/><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_A_State' aria-label=\"Choose A State\">Choose A State<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_A_State\" id=\"ff_5_Choose_A_State\" class=\"ff-el-form-control\" data-name=\"Choose_A_State\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Please Choose A State -<\/option><option value=\"Arizona\"  >Arizona<\/option><option value=\"Florida\"  >Florida<\/option><option value=\"Indiana\"  >Indiana<\/option><option value=\"Iowa\"  >Iowa<\/option><option value=\"Kansas\"  >Kansas<\/option><option value=\"Missouri\"  >Missouri<\/option><option value=\"Nebraska\"  >Nebraska<\/option><option value=\"Ohio\"  >Ohio<\/option><option value=\"Oklahoma\"  >Oklahoma<\/option><option value=\"Texas\"  >Texas<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Arizona_Location' aria-label=\"Choose Arizona Location\">Choose Arizona Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Arizona_Location\" id=\"ff_5_Arizona_Location\" class=\"ff-el-form-control\" data-name=\"Arizona_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Arizona Location -<\/option><option value=\"Apache Junction\"  >Apache Junction<\/option><option value=\"Casa Grande\"  >Casa Grande<\/option><option value=\"Cottonwood\"  >Cottonwood<\/option><option value=\"Green Valley\"  >Green Valley<\/option><option value=\"Prescott Valley\"  >Prescott Valley<\/option><option value=\"Sun City West\"  >Sun City West<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Florida_Location' aria-label=\"Choose Florida Location\">Choose Florida Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Florida_Location\" id=\"ff_5_Choose_Florida_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Florida_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Florida Location -<\/option><option value=\"Clermont\"  >Clermont<\/option><option value=\"Fort Myers\"  >Fort Myers<\/option><option value=\"Fort Walton Beach\"  >Fort Walton Beach<\/option><option value=\"Milton\"  >Milton<\/option><option value=\"Ocala\"  >Ocala<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Indiana_Location' aria-label=\"Choose Indiana Location\">Choose Indiana Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Indiana_Location\" id=\"ff_5_Choose_Indiana_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Indiana_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Indiana Location -<\/option><option value=\"Evansville\"  >Evansville<\/option><option value=\"Terre Haute\"  >Terre Haute<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Iowa_Location' aria-label=\"Choose Iowa Location\">Choose Iowa Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Iowa_Location\" id=\"ff_5_Choose_Iowa_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Iowa_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Iowa Location -<\/option><option value=\"Council Bluff\"  >Council Bluff<\/option><option value=\"Davenport\"  >Davenport<\/option><option value=\"Denison\"  >Denison<\/option><option value=\"Des Moines\"  >Des Moines<\/option><option value=\"Shenandoah\"  >Shenandoah<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Kansas_Location' aria-label=\"Choose Kansas Location\">Choose Kansas Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Kansas_Location\" id=\"ff_5_Choose_Kansas_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Kansas_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Kansas Location -<\/option><option value=\"Emporia\"  >Emporia<\/option><option value=\"Hutchinson\"  >Hutchinson<\/option><option value=\"Ottawa\"  >Ottawa<\/option><option value=\"Pittsburg\"  >Pittsburg<\/option><option value=\"Russell\"  >Russell<\/option><option value=\"Topeka\"  >Topeka<\/option><option value=\"Wakeensy\"  >Wakeensy<\/option><option value=\"Wichita\"  >Wichita<\/option><option value=\"Winfield\"  >Winfield<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Missouri_Location' aria-label=\"Choose Missouri Location\">Choose Missouri Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Missouri_Location\" id=\"ff_5_Choose_Missouri_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Missouri_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Missouri Location -<\/option><option value=\"Joplin\"  >Joplin<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Nebraska_Location' aria-label=\"Choose Nebraska Location\">Choose Nebraska Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Nebraska_Location\" id=\"ff_5_Choose_Nebraska_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Nebraska_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Nebraska Location -<\/option><option value=\"Columbus\"  >Columbus<\/option><option value=\"Kearney\"  >Kearney<\/option><option value=\"Grand Island\"  >Grand Island<\/option><option value=\"Lincoln\"  >Lincoln<\/option><option value=\"Omaha\"  >Omaha<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Ohio_Location' aria-label=\"Choose Ohio Location\">Choose Ohio Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Ohio_Location\" id=\"ff_5_Choose_Ohio_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Ohio_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Ohio Location -<\/option><option value=\"Anon Lake\"  >Anon Lake<\/option><option value=\"Fairlawn\"  >Fairlawn<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Oklahoma_Location' aria-label=\"Choose Oklahoma Location\">Choose Oklahoma Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Oklahoma_Location\" id=\"ff_5_Choose_Oklahoma_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Oklahoma_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Oklahoma Location -<\/option><option value=\"Altus\"  >Altus<\/option><option value=\"Bartlesville\"  >Bartlesville<\/option><option value=\"Broken Arrow\"  >Broken Arrow<\/option><option value=\"Clinton\"  >Clinton<\/option><option value=\"Enid\"  >Enid<\/option><option value=\"McAlester\"  >McAlester<\/option><option value=\"Muskogee\"  >Muskogee<\/option><option value=\"Oklahoma City\"  >Oklahoma City<\/option><option value=\"Ponca City\"  >Ponca City<\/option><option value=\"Pryor\"  >Pryor<\/option><option value=\"Tahlequah\"  >Tahlequah<\/option><\/select><\/div><\/div><div class='ff-el-group ff-el-form-hide_label has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Choose_Texas_Location' aria-label=\"Choose Texas Location\">Choose Texas Location<\/label><\/div><div class='ff-el-input--content'><select name=\"Choose_Texas_Location\" id=\"ff_5_Choose_Texas_Location\" class=\"ff-el-form-control\" data-name=\"Choose_Texas_Location\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">- Choose Texas Location -<\/option><option value=\"Abilene\"  >Abilene<\/option><option value=\"Bay City\"  >Bay City<\/option><option value=\"Baytown\"  >Baytown<\/option><option value=\"Bowie\"  >Bowie<\/option><option value=\"Conroe\"  >Conroe<\/option><option value=\"Decator\"  >Decator<\/option><option value=\"Georgetown\"  >Georgetown<\/option><option value=\"Greenville\"  >Greenville<\/option><option value=\"Gainesville\"  >Gainesville<\/option><option value=\"Gun Barrel City\"  >Gun Barrel City<\/option><option value=\"Lake Jackson\"  >Lake Jackson<\/option><option value=\"Lubbock\"  >Lubbock<\/option><option value=\"Liberty\"  >Liberty<\/option><option value=\"Midland\"  >Midland<\/option><option value=\"Nacogdoches\"  >Nacogdoches<\/option><option value=\"Odessa\"  >Odessa<\/option><option value=\"Palestine\"  >Palestine<\/option><\/select><\/div><\/div><\/div><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_names_first_name_' aria-label=\"First Name\">First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_5_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_names_last_name_' aria-label=\"Last Name\">Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_5_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_datetime' aria-label=\"Date \/ Time\">Date \/ Time<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='M\/d\/Y' type=\"text\" name=\"datetime\" id=\"ff_5_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Checkbox Field\">Checkbox Field<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Sex_9830638455d801084eb26b71fa1c7d76><input  type=\"checkbox\" name=\"Sex[]\" data-name=\"Sex\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Female\"  id='Sex_9830638455d801084eb26b71fa1c7d76' aria-label='Female' aria-invalid='false' aria-required=false> <span>Female<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=Sex_125d334ab13c2425669433d93d0537a6><input  type=\"checkbox\" name=\"Sex[]\" data-name=\"Sex\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Male\"  id='Sex_125d334ab13c2425669433d93d0537a6' aria-label='Male' aria-invalid='false' aria-required=false> <span>Male<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Email_Address' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"Email_Address\" id=\"ff_5_Email_Address\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"Email_Address\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Phone_Number' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input name=\"Phone_Number\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Phone Number\" data-name=\"Phone_Number\" id=\"ff_5_Phone_Number\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=Address>Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_5_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_5_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_5_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_5_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_5_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_Payor_Source' aria-label=\"Payor Source:\">Payor Source:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Payor_Source\" class=\"ff-el-form-control\" data-name=\"Payor_Source\" id=\"ff_5_Payor_Source\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_Physician_NPP_Office_Contact_Phone' aria-label=\"Physician \/ NPP Office Contact Phone #:\">Physician \/ NPP Office Contact Phone #:<\/label><\/div><div class='ff-el-input--content'><input name=\"Physician_NPP_Office_Contact_Phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"Physician_NPP_Office_Contact_Phone\" id=\"ff_5_Physician_NPP_Office_Contact_Phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text' aria-label=\"Primary DX:\">Primary DX:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_5_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Orders (Check All That Apply)\">Orders (Check All That Apply)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_e800e7e22d378e9daa53bb2769e68cbb><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Assess for Homebound Status and Eligibility and Admit to Angles Care Home Health\"  id='checkbox_e800e7e22d378e9daa53bb2769e68cbb' aria-label='Assess for Homebound Status and Eligibility and Admit to Angles Care Home Health' aria-invalid='false' aria-required=true> <span>Assess for Homebound Status and Eligibility and Admit to Angles Care Home Health<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_e4b954e9a070a26aca202d23e2bf8128><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Has Patient Had A Recent Face-To-Face\"  id='checkbox_e4b954e9a070a26aca202d23e2bf8128' aria-label='Has Patient Had A Recent Face-To-Face' aria-invalid='false' aria-required=true> <span>Has Patient Had A Recent Face-To-Face<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_file-upload_1' aria-label=\"Please Upload Supporting \/ Additional Documents #1\">Please Upload Supporting \/ Additional Documents #1<\/label><\/div><div class='ff-el-input--content'><label for='ff_5_file-upload_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload\" id=\"ff_5_file-upload_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_file-upload_4_1' aria-label=\"Please Upload Supporting \/ Additional Documents #2\">Please Upload Supporting \/ Additional Documents #2<\/label><\/div><div class='ff-el-input--content'><label for='ff_5_file-upload_4_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload_4\" id=\"ff_5_file-upload_4_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload_4\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_file-upload_3_1' aria-label=\"Please Upload Supporting \/ Additional Documents #3\">Please Upload Supporting \/ Additional Documents #3<\/label><\/div><div class='ff-el-input--content'><label for='ff_5_file-upload_3_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload_3\" id=\"ff_5_file-upload_3_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload_3\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_file-upload_2_1' aria-label=\"Please Upload Supporting \/ Additional Documents #4\">Please Upload Supporting \/ Additional Documents #4<\/label><\/div><div class='ff-el-input--content'><label for='ff_5_file-upload_2_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload_2\" id=\"ff_5_file-upload_2_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload_2\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_file-upload_1_1' aria-label=\"Please Upload Supporting \/ Additional Documents #5\">Please Upload Supporting \/ Additional Documents #5<\/label><\/div><div class='ff-el-input--content'><label for='ff_5_file-upload_1_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload_1\" id=\"ff_5_file-upload_1_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload_1\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I Am A:\">I Am A:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_4a93583e57a87e02762d4874a47b2c1e><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Physician\"  id='checkbox_1_4a93583e57a87e02762d4874a47b2c1e' aria-label='Physician' aria-invalid='false' aria-required=true> <span>Physician<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_f110010e750c4cb4a12d6f5a2121b251><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Nurse Practitioner (NP)\"  id='checkbox_1_f110010e750c4cb4a12d6f5a2121b251' aria-label='Nurse Practitioner (NP)' aria-invalid='false' aria-required=true> <span>Nurse Practitioner (NP)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_3274333cabfeec20e06046dfb60e6ee0><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Physician Assistant (PA)\"  id='checkbox_1_3274333cabfeec20e06046dfb60e6ee0' aria-label='Physician Assistant (PA)' aria-invalid='false' aria-required=true> <span>Physician Assistant (PA)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_84ebfdc12f89210df34eba4557ecb812><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Clinical Nurse Specialist (CNS)\"  id='checkbox_1_84ebfdc12f89210df34eba4557ecb812' aria-label='Clinical Nurse Specialist (CNS)' aria-invalid='false' aria-required=true> <span>Clinical Nurse Specialist (CNS)<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_input_text_1' aria-label=\"Electronic Signature Needed\">Electronic Signature Needed<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" placeholder=\"Physician \/ NPP Signature Required\" data-name=\"input_text_1\" id=\"ff_5_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_input_text_2' aria-label=\"NPI\">NPI<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_5_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_5_datetime_1' aria-label=\"Date \/ Time\">Date \/ Time<\/label><\/div><div class='ff-el-input--content'><input data-type-datepicker data-format='M\/d\/Y' type=\"text\" name=\"datetime_1\" id=\"ff_5_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Submit Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_5_errors' class='ff-errors-in-stack ff_form_instance_5_1 ff-form-loading_errors ff_form_instance_5_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_5_1 = {\"id\":\"5\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_5_1\",\"form_id_selector\":\"fluentform_5\",\"rules\":{\"Choose_A_State\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Arizona_Location\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Choose_Florida_Location\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Choose_Indiana_Location\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Choose_Iowa_Location\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Choose_Kansas_Location\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Choose_Missouri_Location\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Choose_Nebraska_Location\":{\"required\":{\"value\":true,\"message\":\"This field is 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required\",\"global\":false,\"global_message\":\"This field is required\"}},\"datetime\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Sex\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Email_Address\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\",\"global\":false,\"global_message\":\"This field must contain a valid email\"}},\"Phone_Number\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":false,\"message\":\"Phone number is not valid\",\"global\":false,\"global_message\":\"Phone number is not valid\"}},\"address_1[address_line_1]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"address_1[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"address_1[city]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"address_1[state]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"address_1[zip]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"address_1[country]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Payor_Source\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"Physician_NPP_Office_Contact_Phone\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":false,\"message\":\"Phone number is not valid\",\"global\":false,\"global_message\":\"Phone number is not valid\"}},\"input_text\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"checkbox\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"file-upload\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is 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maximum 1 file\",\"global\":false,\"global_message\":\"Validation fails for maximum file count\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"jpg|jpeg|gif|png|bmp\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\",\"global\":false,\"global_message\":\"Invalid file type\"}},\"file-upload_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"},\"max_file_size\":{\"value\":1048576,\"_valueFrom\":\"MB\",\"message\":\"Maximum file size limit is 1MB\",\"global\":false,\"global_message\":\"Validation fails for maximum file size\"},\"max_file_count\":{\"value\":1,\"message\":\"You can upload maximum 1 file\",\"global\":false,\"global_message\":\"Validation fails for maximum file count\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"jpg|jpeg|gif|png|bmp\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\",\"global\":false,\"global_message\":\"Invalid file type\"}},\"file-upload_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"},\"max_file_size\":{\"value\":1048576,\"_valueFrom\":\"MB\",\"message\":\"Maximum file size limit is 1MB\",\"global\":false,\"global_message\":\"Validation fails for maximum file size\"},\"max_file_count\":{\"value\":1,\"message\":\"You can upload maximum 1 file\",\"global\":false,\"global_message\":\"Validation fails for maximum file count\"},\"allowed_file_types\":{\"value\":[\"pdf\",\"jpg|jpeg|gif|png|bmp\",\"doc|ppt|pps|xls|mdb|docx|xlsx|pptx|odt|odp|ods|odg|odc|odb|odf|rtf|txt\"],\"message\":\"Invalid file type\",\"global\":false,\"global_message\":\"Invalid file type\"}},\"file-upload_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is 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required\",\"global\":false,\"global_message\":\"This field is required\"}},\"datetime_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}}},\"conditionals\":{\"Arizona_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Arizona\",\"operator\":\"=\"}]},\"Choose_Florida_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Florida\",\"operator\":\"=\"}]},\"Choose_Indiana_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Indiana\",\"operator\":\"=\"}]},\"Choose_Iowa_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Iowa\",\"operator\":\"=\"}]},\"Choose_Kansas_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Kansas\",\"operator\":\"=\"}]},\"Choose_Missouri_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Missouri\",\"operator\":\"=\"}]},\"Choose_Nebraska_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Nebraska\",\"operator\":\"=\"}]},\"Choose_Ohio_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Ohio\",\"operator\":\"=\"}]},\"Choose_Oklahoma_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Oklahoma\",\"operator\":\"=\"}]},\"Choose_Texas_Location\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"Choose_A_State\",\"value\":\"Texas\",\"operator\":\"=\"}]}}};\n                    <\/script>\n                    <\/div>\n\n            \t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-59383cef elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"59383cef\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-671cc18d\" data-id=\"671cc18d\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6b7310b4 elementor-widget elementor-widget-heading\" data-id=\"6b7310b4\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Specialty Programs<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-2aaa9429 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2aaa9429\" data-element_type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-583eaf69\" data-id=\"583eaf69\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-22b2a4c fontcolorGreen elementor-position-top elementor-widget elementor-widget-image-box\" data-id=\"22b2a4c\" data-element_type=\"widget\" data-widget_type=\"image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-image-box-wrapper\"><figure class=\"elementor-image-box-img\"><a href=\"\/behavioral-health-at-home\/\" tabindex=\"-1\"><img fetchpriority=\"high\" decoding=\"async\" width=\"320\" height=\"221\" src=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Behavioral-Health-at-Home-320x221-1.jpg\" class=\"attachment-full size-full wp-image-2993\" alt=\"Behavioral Health at Home\" srcset=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Behavioral-Health-at-Home-320x221-1.jpg 320w, https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Behavioral-Health-at-Home-320x221-1-300x207.jpg 300w\" sizes=\"(max-width: 320px) 100vw, 320px\" \/><\/a><\/figure><div class=\"elementor-image-box-content\"><h3 class=\"elementor-image-box-title\"><a href=\"\/behavioral-health-at-home\/\">Behavioral Health at Home<\/a><\/h3><\/div><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-68c3d7c1\" data-id=\"68c3d7c1\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-48ff3204 elementor-position-top elementor-widget elementor-widget-image-box\" data-id=\"48ff3204\" data-element_type=\"widget\" data-widget_type=\"image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-image-box-wrapper\"><figure class=\"elementor-image-box-img\"><a href=\"\/care-connections-pre-palliative-care\/\" tabindex=\"-1\"><img decoding=\"async\" width=\"320\" height=\"221\" src=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Care-Connections-320x221-1.jpg\" class=\"attachment-full size-full wp-image-2994\" alt=\"Care Connections Pre-Palliative Care\" srcset=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Care-Connections-320x221-1.jpg 320w, https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Care-Connections-320x221-1-300x207.jpg 300w\" sizes=\"(max-width: 320px) 100vw, 320px\" \/><\/a><\/figure><div class=\"elementor-image-box-content\"><h3 class=\"elementor-image-box-title\"><a href=\"\/care-connections-pre-palliative-care\/\">Care Connections Pre-Palliative Care<\/a><\/h3><\/div><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-3aab9b64\" data-id=\"3aab9b64\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4f26bf5e elementor-position-top elementor-widget elementor-widget-image-box\" data-id=\"4f26bf5e\" data-element_type=\"widget\" data-widget_type=\"image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-image-box-wrapper\"><figure class=\"elementor-image-box-img\"><a href=\"\/take-a-breath-respiratory-care-program\/\" tabindex=\"-1\"><img decoding=\"async\" width=\"320\" height=\"221\" src=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/take-a-breath-footer-320-221.jpg\" class=\"attachment-full size-full wp-image-2997\" alt=\"Take A Breath respirator Care Program\" srcset=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/take-a-breath-footer-320-221.jpg 320w, https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/take-a-breath-footer-320-221-300x207.jpg 300w\" sizes=\"(max-width: 320px) 100vw, 320px\" \/><\/a><\/figure><div class=\"elementor-image-box-content\"><h3 class=\"elementor-image-box-title\"><a href=\"\/take-a-breath-respiratory-care-program\/\">Take A Breath Respiratory Program<\/a><\/h3><\/div><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-2c91a7d2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2c91a7d2\" data-element_type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-281cc7d6\" data-id=\"281cc7d6\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5baa8b5c elementor-position-top elementor-widget elementor-widget-image-box\" data-id=\"5baa8b5c\" data-element_type=\"widget\" data-widget_type=\"image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-image-box-wrapper\"><figure class=\"elementor-image-box-img\"><a href=\"\/anxiety-and-depression-chronic-care\/\" tabindex=\"-1\"><img loading=\"lazy\" decoding=\"async\" width=\"320\" height=\"221\" src=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/anxiety-and-depression-footer-320-221.jpg\" class=\"attachment-full size-full wp-image-2992\" alt=\"Anxiety and Depression Chronic Care\" srcset=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/anxiety-and-depression-footer-320-221.jpg 320w, https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/anxiety-and-depression-footer-320-221-300x207.jpg 300w\" sizes=\"(max-width: 320px) 100vw, 320px\" \/><\/a><\/figure><div class=\"elementor-image-box-content\"><h3 class=\"elementor-image-box-title\"><a href=\"\/anxiety-and-depression-chronic-care\/\">Anxiety and Depression Chronic Care<\/a><\/h3><\/div><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-78b3f7ca\" data-id=\"78b3f7ca\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-73d05ee3 elementor-position-top elementor-widget elementor-widget-image-box\" data-id=\"73d05ee3\" data-element_type=\"widget\" data-widget_type=\"image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-image-box-wrapper\"><figure class=\"elementor-image-box-img\"><a href=\"\/pain-management-program-2\/\" tabindex=\"-1\"><img loading=\"lazy\" decoding=\"async\" width=\"320\" height=\"221\" src=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/pain-management-program-footer-320-221.jpg\" class=\"attachment-full size-full wp-image-2996\" alt=\"Pain Management Program\" srcset=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/pain-management-program-footer-320-221.jpg 320w, https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/pain-management-program-footer-320-221-300x207.jpg 300w\" sizes=\"(max-width: 320px) 100vw, 320px\" \/><\/a><\/figure><div class=\"elementor-image-box-content\"><h3 class=\"elementor-image-box-title\"><a href=\"\/pain-management-program-2\/\">Pain Management Program<\/a><\/h3><\/div><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-217457e0\" data-id=\"217457e0\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-65490184 elementor-position-top elementor-widget elementor-widget-image-box\" data-id=\"65490184\" data-element_type=\"widget\" data-widget_type=\"image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-image-box-wrapper\"><figure class=\"elementor-image-box-img\"><a href=\"\/community-classroom-and-caregiver-support-education\/\" tabindex=\"-1\"><img loading=\"lazy\" decoding=\"async\" width=\"320\" height=\"221\" src=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Community-Classroom-CGS-Footer-320-221.jpg\" class=\"attachment-full size-full wp-image-2995\" alt=\"Community Classroom and Caregiver Support Education\" srcset=\"https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Community-Classroom-CGS-Footer-320-221.jpg 320w, https:\/\/www.angelscarehealth.com\/wp-content\/uploads\/2020\/05\/Community-Classroom-CGS-Footer-320-221-300x207.jpg 300w\" sizes=\"(max-width: 320px) 100vw, 320px\" \/><\/a><\/figure><div class=\"elementor-image-box-content\"><h3 class=\"elementor-image-box-title\"><a href=\"\/community-classroom-and-caregiver-support-education\/\">Community Classroom and Caregiver Support Education<\/a><\/h3><\/div><\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Please fill out the form and attach any supporting documents (History and Physical, Diagnostic Tests, and Labs) to be submitted. PHY \/ NPP referral Form &#916; Choose A State &#8211; Please Choose A State &#8211;ArizonaFloridaIndianaIowaKansasNebraskaOhioOklahomaTexasChoose Arizona Location &#8211; Choose Arizona Location &#8211;Apache JunctionCasa GrandeCottonwoodGreen ValleyPrescott ValleySun City WestChoose Florida Location &#8211; Choose Florida Location &#8211;ClemontFort&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"categories":[],"tags":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>PHY\/NPP Referral Form - Angels Care Home Health<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.angelscarehealth.com\/phy-npp-referral-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"PHY\/NPP Referral Form - Angels Care Home Health\" \/>\n<meta property=\"og:description\" content=\"Please fill out the form and attach any supporting documents (History and Physical, Diagnostic Tests, and Labs) to be submitted. 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