Refer a patient in three quick steps
A secure intake built for hospital discharge planners, case managers and primary care teams. Attach your clinical records once — we handle Medicare certification from there.
Encrypted & private
Clinical records travel over an encrypted connection into private storage, visible only to our clinical team.
Medicare-compliant intake
The form captures the FTF note, PECOS status and homebound criteria CMS requires.
Fast turnaround
Urgent referrals are reviewed within two business hours by our intake coordinators.
HIPAA-secure referral portal
This form is fully secure and HIPAA-compliant. Patient health information is protected.
Urgent referral? If the patient needs an immediate, same-day evaluation, call our intake line at (610) 931-0114 before submitting this form.
Patient Demographics
Patient and referrer details
Clinical & Payer Data
Diagnosis, payer and skilled need
Document Upload
Attach the clinical records
Referrer information
Who is ordering the care, and who we should call with updates.
Patient information
Used for the initial assessment and geography checks.
Encrypted transmission. Records are stored privately and released only to Humble Hands clinical staff.
Download a blank paper referral checklist
Many hospital case managers still submit on paper. Download the checklist, complete it by hand, attach the clinical records and fax it across — it captures the same Medicare details this portal collects.
Fax completed forms to
(763) 273-4666
The right care starts with a simple conversation.
Let's talk about what your loved one needs. Our advisors are ready to help — (610) 931-0114.