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”.

 
  • Patient First Name


    Demographics: Name, Address, SS#, DOB, InsuranceHome Health Orders


    SNPTOTSTMSWHH Aide

 

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”.

 
  • Patient First Name


    Demographics: Name, Address, SS#, DOB, InsuranceOrder: Hospice Eval and Treat or Admit and DX

    Contract RequiredValid Diagnosis



    YesNo

 

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
  • Virginia Premier CompleteCare
  • HealthKeepers
  • Humana
  • VA Pay
  • Workers Compensation
  • Anthem
  • TRICARE (Standard and For Life)
  • Blue Cross Blue Shield
  • Medicaid: Optima, VA Premier, HealthKeepers, Virginia Medicaid

We are unable to accept the following insurance policies:

  • United
  • Aetna
  • Cigna
  • Coventry
James River Home Health