Home Care Referral Form Template
Streamline Client Referrals with Our Easy-to-Use Template
Struggling to manage client referrals between home care agencies? This template is designed for home care professionals seeking a seamless way to refer clients for additional nursing services. With a clear layout and easy-to-fill fields, you can improve coordination among agencies, ensure timely service delivery, and enhance client satisfaction. Plus, it's simple to customize and WCAG-aligned for accessibility. Start optimizing your referral process today with our live template.
When to use this form
Use this form when you need to start home-based services for a patient after a hospital stay, a new diagnosis, or a decline in function. Care coordinators, physicians, and family caregivers use it to request skilled nursing, therapy, or aide support and to share key details for safe care at home. It is ideal for time-sensitive needs like wound care within 48 hours, medication setup after discharge, or fall-risk monitoring. If a provider is handing off care, pair it with a Doctor referral form to keep orders clear. For cross-facility transfers or general intake, the Patient referral form helps capture broader history, then this form focuses scheduling and visit needs.
Must Ask Home Care Referral Questions
- Who is the person needing care, and who is the primary contact?
Collect full name, date of birth, address, phone, and caregiver details to identify the case and schedule safely. If the individual is initiating services, you can pair this intake with a Self referral form.
- What diagnoses, recent events, and risks should we know about?
Clinical context such as primary diagnosis, recent hospitalization, falls, wounds, or cognitive issues guides the right disciplines and visit frequency. Clear history reduces callbacks and prevents gaps in orders and supplies.
- Which home care services do you need and when should they start?
Stating nursing, PT/OT/speech, or home health aide needs with a preferred start date lets intake match capacity and urgency. It also sets expectations for the first 72 hours, when outcomes are most sensitive.
- Who is the referring provider and what insurance or authorization applies?
Listing physician name, NPI, orders, and payer details speeds verification and ensures compliant billing. This aligns with a Doctor referral form workflow when the request comes from a clinic.
- What is the home environment and are there safety or language needs?
Notes about stairs, pets, equipment, transportation, and language access shape visit planning and safety. For broader social supports like food, benefits, or housing, route needs through a Social services referral form.
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