Refer a Patient 1800 Home Health

Referral Form

Please complete the referral patient form below.

Patient Information

Name *

First

Last

Email Address *

Phone

Date of Birth *

mm/dd/yyyy

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Referral Source Info

First Name *

Referring Provider/Case Manager First Name

Last Name *

Referring Provider/Case Manager Last Name

Clinic/Hospital Name *

Provider Phone Number *

Provider Email *

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Care and Insurance Info

Check all that apply

Insurance Type

Medicare
Medicaid
Private Insurance
Private Pay

Reason for Referral

Brief notes stating reason for referral

Preferred start date *

mm/dd/yyyy

I have authorization to share this patients information *

Yes
No

Attach Patient Care Plans and Consent Forms

Drag & Drop Files, Choose Files to Upload

Want updates by SMS? (optional)

I agree to receive SMS messages from 1800 Home Health.

Message frequency may vary. Message & data rates may apply. Reply STOP at any time to unsubscribe.

We respect your privacy. Your information will only be used to respond to your request and provide relevant updates. See our Privacy Policy and Terms of Services for more details. *

We respect your privacy. Your information will only be used to respond to your request and provide relevant updates. See our Privacy Policy and Terms of Services for more details.

This form is encrypted and stored securely in accordance with HIPAA regulations. Please do not submit emergency requests. If this is a medical emergency, call 911.

How Home Health Referrals Work?

Home health referrals connect patients with licensed home health agencies after a hospital stay or physician order. The process ensures patients receive appropriate care at home based on medical needs, insurance, and location.

How the Home Health Referral Process Works

Referral Initiation
A physician, hospital discharge planner, or case manager determines that home health services are needed.
Patient Information Review
Care needs, insurance coverage, location, and physician orders are reviewed.
Agency Matching
Patients are matched with licensed and CMS-certified home health agencies that can meet their care requirements.
Secure Referral Transmission
Referral details are shared through a HIPAA-conscious workflow to protect patient information.
Agency Acceptance & Start of Care
The selected agency accepts the referral and coordinates the start of home health services.

Why Home Health Referrals Matter

Support safe transitions from hospital to home
Reduce readmissions
Ensure continuity of care
Connect patients with verified providers

Referral Form

Patient Information

Referral Source Info

Care and Insurance Info

Reason for Referral

How Home Health Referrals Work?

For Patients & Families

Home Health Agencies

Hospitals/care managers

Legal

Referral Form

Patient Information

Referral Source Info

Care and Insurance Info

Reason for Referral

How Home Health Referrals Work?

For Patients & Families

Home Health Agencies

Hospitals/care managers

Legal

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