(For Healthcare Providers Only)
Phone: (518) 489-2681 Intake fax: (518) 489-2532
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)
*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
If diabetic – include parameters
If wound care – include orders and wound measurements
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.