Initiate a Referral

Phone:  (518) 489-2681
Intake fax:  (518) 489-2532
Intake Hours:
8:00 am – 5:00 pm Monday – Friday
7:30 am – 4:00 pm Saturday
7:30 am – 12 noon Sunday

To initiate a referral please fax the following patient information to VNA Home Health Intake:

Completed VNA referral form (signed by MD or DO)

Patient demographic information including:

  • insurance information
  • current address/phone number

Current diagnosis list (this must have a physician signature on it)

Most recent visit notes to summarize patient’s current status

Current medication list

List of services you are requesting with orders outlining the purpose for each service

Face to Face form for ALL MEDICARE PATIENTS (may serve as an order form for home health care orders)

Name and contact information of person sending referral


If diabetic – include parameters

If wound care – include orders and wound measurements

Other:  ___________________________

If you have any questions or need for assistance in completing a referral, please contact our Intake Department, they will be happy to assist you.

  • Upon receipt of referral, VNA will contact the patient to set up the first appointment.
  • After the first appointment, VNA will fax Form 485(Plan of Care) to your office.  It is necessary that this form be signed by the physician and faxed back to VNA Home Health at: (518) 489-2532 to commence care and meet New York State regulations.

Download forms here:
VNA Referral Form
How to request VNA Home Health Services

Face to Face Form
How to fill out Face to Face Form