OSF Home Care Services

Referral Request Form

Thank you for your interest in OSF Home Care Services. To start the referral process, please fill out the following form and provide the requested documents below.

Note: This form is for physicians and health care providers only. If you wish to refer yourself or a loved one, please call Admission Services at (800) 673-5288.

* indicates a required field.

Referral Source

Please provide the following information about the person making the referral on behalf of the patient.

Please provide the best phone number to reach you for questions and follow-up.

Patient Information

Please provide the following information about the patient being referred for services.

Example: Jr., Sr., III
Please use MM/DD/YYYY format.

Patient Documents

The following documents are required to start the referral process. Please use the fields below to upload Word or PDF documents.

Combined file sizes cannot exceed 10MB
Combined file sizes cannot exceed 10MB
Combined file sizes cannot exceed 10MB
Note: Medicare/Medicaid patients require Face to Face for medical equipment and home health. Combined file sizes cannot exceed 10MB

We respect and safeguard your privacy. This form is secure.