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.
* First Name:
* Last Name:
* Phone:	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.
* First Name:
M.I.:
* Last Name:
Suffix:	Example: Jr., Sr., III
* Date of Birth:	Please use MM/DD/YYYY format.
* City & State Where Patient Resides:
* Which division are you referring this patient to?:
Services Requested:	Skilled Nursing Physical Therapy Speech Therapy
Patient Documents The following documents are required to start the referral process. Please use the fields below to upload Word or PDF documents.
* Facesheet:	Combined file sizes cannot exceed 15MB
* History & Physical:	Combined file sizes cannot exceed 15MB
* Medication List:	Combined file sizes cannot exceed 15MB
* Physician Order or Face to Face:	Note: Medicare/Medicaid patients require Face to Face for medical equipment and home health. Combined file sizes cannot exceed 15MB

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

Referral Request Form

Referral Source

Patient Information

Patient Documents