Refer a Client | ABC LifeCare

Refer Yourself for Care

You are looking for home care for yourself or someone you legally represent. Fill out what you know — we will work through the rest when we talk.

Your Information

First Name *

Last Name *

Date of Birth *

Phone *

Email (optional)

Best time to call

Street Address *

Apt / Unit (if applicable)

City *

State *

ZIP *

Care You Are Seeking

Payment Path *

Primary Diagnosis or Condition (if applicable)

What kind of help do you need?

Hours per week needed (estimate)

When would you like to start?

Anything Else We Should Know?

Notes (optional)

I confirm I am the client or their legal representative, and I would like ABC LifeCare to contact me about home care. *

By submitting, you understand that ABC LifeCare will store this information securely and use it only to evaluate your eligibility for our services and follow up with you. We never sell your information. See our Privacy & HIPAA Notice.

Goes directly to intake@abclifecare.com. We respond within one business day.

Refer a Family Member or Friend

Sharing someone's name with us. Tell us what you know — even if it is only a name and phone number. We will reach out carefully.

The Person You Are Referring

Their First Name *

Their Last Name *

Their Phone (if known)

Their Email (if known)

City (if known)

ZIP (if known)

Their Approximate Age (if known)

What kind of help do they need?

About You

Your First Name *

Your Last Name *

Your Phone *

Your Email *

Your Relationship to Them *

Tell Us a Bit More

Why are you reaching out on their behalf?

Has the Person You Are Referring Been Told?

Yes — they know I am reaching out and asked me to, or said it was OK

Not yet — please contact me first before reaching out to them

We treat every referral with discretion. If the person has not been told, we will contact you first to talk through the best approach. We never identify the referrer to the client without your permission.

Goes directly to intake@abclifecare.com. We respond within one business day.

Physician or Provider Referral

For physicians, case managers, hospital discharge planners, and other providers referring a patient for home care. We coordinate with the patient and your office.

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Patient Phone (if known)

Patient Address (if known)

City & ZIP (if known)

Primary Diagnosis *

ICD-10 Code(s) (optional)

Insurance / Payment Path *

Care Requested

Type of Care *

Estimated Hours per Week

Urgency *

Clinical Notes (optional)

Referring Provider

Provider Name *

NPI (optional)

Practice / Facility *

Role / Specialty

Best Contact Phone *

Email *

Patient Aware of Referral?

Sending supporting documents?
After submitting this form, please email signed referral, plan of care, H&P, recent progress notes, and any relevant assessments to intake@abclifecare.com. Include the patient name and your practice in the subject line. For HIPAA-compliant fax, call us at (816) 256-8672 for our secure fax number.

I attest that I have legitimate clinical reason to refer this patient, and that the patient (or legal representative) has consented or will consent to this referral. *

Information shared on this form is treated as PHI. ABC LifeCare uses HIPAA-compliant intake procedures. See our Privacy & HIPAA Notice.

Goes directly to intake@abclifecare.com. We respond within one business day. Urgent discharge referrals: call (816) 256-8672.

Connect someone to compassionate care.

Refer Yourself for Care

Refer a Family Member or Friend

Physician or Provider Referral

Prefer a phone conversation?