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Home Health Referral Form Template

Streamline Your Referrals for Home Health Care

Navigating home health care can be complex and time-consuming, especially when you need to ensure that patients receive the right support. This home health referral form template is designed for healthcare providers looking to efficiently recommend services for patients in need of home care. With easy customization options, you can quickly create a compliant form that ensures accurate information capture, simplifies the referral process, and enhances communication between agencies. Whether you need to share a form digitally or embed it on your website, this template helps you provide essential care seamlessly. Try out the live template today!

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Referrer full name
Referrer phone
Referrer email
Who is making this referral?
Physician
Nurse
Case manager
Social worker
Therapist
Hospital discharge planner
Family member
Self
Other
Please Specify:
Patient full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary language
English
Spanish
Chinese
Arabic
Vietnamese
Prefer not to say
Other
Please Specify:
Full home address
Patient phone
Preferred contact method
Phone
Email
Text message
Any
Reason for referral or primary concern
Services requested
Please Specify:
Preferred start of care date
Homebound status for Medicare eligibility
Yes
No
Uncertain/Not assessed
Primary diagnosis (ICD code or description)
Recent hospitalization or ER visit in the past 14 days
Yes
No
Unknown
Allergies (medications, foods, latex, etc.)
Mobility and fall risk
No assistance needed
Uses cane/walker
Uses wheelchair
Bedbound
High fall risk (per clinician assessment)
Unknown
Equipment currently used at home
Please Specify:
Insurance carrier name
Member/Subscriber ID
Primary coverage type
Medicare
Medicaid
Private insurance
Workers' compensation
Uninsured/self-pay
Unknown
Other
Please Specify:
Primary caregiver name (if any)
Caregiver phone
Emergency contact phone
Preferred visit times and any access instructions (gate codes, pets, parking)
Patient or legal representative is aware of and agrees to this referral
Yes
No
Not sure
Authorization to share medical information with the receiving home health agency
Yes
No
Not sure
I certify the information provided is accurate and complete to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Typed signature (full legal name)
Date of submission
{"name":"Referrer full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Referrer full name, Referrer phone, Referrer email","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a home health referral form for FormCreatorAI article.

When to use this form

This template helps hospitals, clinics, and home health agencies collect complete referrals fast. Use it when a patient leaves the hospital and needs skilled nursing, wound care, or therapy at home. Primary care and specialty practices can use it to coordinate post-op care, IV therapy, or chronic disease support. Social workers can submit details to start services within 24-48 hours. For provider-to-provider handoffs, you can also use the Patient referral form. When a person wants to refer themselves or a family member, try the Self referral form. For private duty or non-skilled services, see the Home care referral form.

Must Ask Home Health Referral Questions

  1. What is the patient's full name, date of birth, address, and best contact?

    These identifiers let your intake team match records, verify eligibility, and schedule without delays. Clear contact details reduce rescheduling and speed up the first visit.

  2. Who is the referring provider and how can we reach you?

    Knowing the ordering clinician ensures we obtain signatures, clarify orders, and share progress notes. In clinic workflows, your team can also route details through the Office referral form.

  3. What diagnoses, recent procedures, and clinical goals should guide care at home?

    This context helps triage acuity and assign the right discipline (RN, PT, OT, ST). Clear goals align the plan of care with discharge instructions and reduce readmissions.

  4. Which services are needed and how often, and what is the requested start-of-care date?

    Listing services and frequency (for example, nursing 2x/week) helps staffing and coverage. A target start date sets expectations and prioritizes urgent cases.

  5. What insurance covers the patient, and is authorization or face-to-face documentation complete?

    Payer details and auth status prevent denials and delays. When this is complete up front, billing is smoother and care can start sooner.

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