Home Health Referral Form

Capture all the patient information you need simply and securely with this home health referral form template. Advanced form security features help you safeguard protected health information with 256-bit SSL, data encryption, and password protection. It’s the simplest, easiest way to create an online patient referral system that lets referring physicians provide social security numbers and other sensitive data without worry.

Because it’s designed with HIPAA compliance in mind, our home health referral form template makes it easy to meet regulatory requirements. For an even more seamless referral process, you can combine it with Formstack Documents to generate HIPAA-friendly patient documents. Secure cloud storage, file access controls, and user-level permissions all help reduce your risk of HIPAA violations, penalties, and fines.

Quickly collect insurance information, Medicaid details, referral notes, and physician signatures—all in the same digital form. Then use Webhooks to send patient data to your EHR. You’ll have all the information you need to follow up on referrals from the start.

Reduce the need for time-consuming follow-up by using Workflows to pass the same referral form from one staff member to another. You can even combine this template with other digital forms to create a more efficient home health admissions process.