Referral Request Form

For questions and/or to check on an existing referral you can:

• Call: (315) 477-4663
• Encrypted email:
  • Aide referrals (Home Health Aide, Personal Care Aide, or Homemaker Services) to lhcsareferrals@nascentiahealth.org
  • Skilled Care referrals (Nursing, Physical, Occupational, or Speech Therapy) to referrals@nascentiahealth.org

Upload referral information below. Here is what we typically look for:

• Demographic Sheet
• Current Medication List
• Treatment Orders
• History and Physical
• Recent Visit Note including PT and / or Notes, if applicable
• Immunization Records

Unable to use our online resource? Referrals can also be completed by downloading the Referral Request Form (pdf), completing it in its entirety and either:

• Encrypted email:
  • Aide referrals (Home Health Aide, Personal Care Aide, or Homemaker Services) to lhcsareferrals@nascentiahealth.org
  • Skilled Care (Nursing, Physical, Occupational, or Speech Therapy) referrals to referrals@nascentiahealth.org
• Fax: 315-477-9584