Home Health Sales Referral Form
Click on the link below to open the form. Please complete the Home Health Sales Referral Form by filling out all fields and clicking “Send”.
Hospice Sales Referral Form
Click on the link below to open the form. Please complete the Hospice Sales Referral Form by filling out all fields and clicking “Send”.
To send your referral:
Download our form below, complete it fully, then fax it to (804) 272-3305.
OR
Use your own electronic order.
You must include these requirements*:
1. F2F Encounter Date: ___________________
2. Primary reason for home health care: _______________________
3. My clinical findings support that this patient is homebound and meets the need for below services because: _______________________________________
4. Skilled disciplines (eg, Skilled Nursing, PT, OT): ___________________
*If these requirements are not included on your referral, we will contact you to fill out this additional information; doctor’s signature required.
We accept referrals using Curaspan and Allscripts.
We accept the following insurance policies:
- Medicare
- HealthKeepers
- Humana
- VA Pay
- Workers Compensation
- Anthem
- TRICARE (Standard and For Life)
- Blue Cross Blue Shield
- Medicaid: Optima, HealthKeepers, Virginia Medicaid
We are unable to accept the following insurance policies:
- United
- Aetna
- Cigna
- Coventry