How to Initiate a Referral

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

To initiate a referral please download, print, and complete the following forms:  

VNA referral form (signed by MD or DO)

Face to Face form*

*Instructions on completing the Face to Face form are available here

When complete, fax the forms above AND the following patient information to VNA Home Health Intake:

Patient demographic information including:

  • insurance information
  • current address/phone number

Current diagnosis list (this must be signed by a physician)

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

Name and contact information of person sending referral

SPECIFIC SERVICES:

If diabetic – include parameters

If wound care – include orders and wound measurements

Other:  ___________________________

If you have any questions or need 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. This form must 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.