Provider & Family Intake

Refer a Patient to Home Health or Hospice

We work collaboratively with physicians, hospital discharge planners, assisted living communities, and families across Sedgwick and 6 surrounding Kansas counties.

Call 24/7 Intake: (316) 869-0015 Online Referral Form ↓

24/7 Phone Line (316) 869-0015

Intake Fax 1 (316) 618-0414

Intake Fax 2 (316) 854-3544

Secure Intake Email info@kansashomehealth.com

Choose the Care Pathway

Refer to Home Health

For skilled nursing, wound care, chronic condition monitoring (CHF, COPD, Diabetes), or physical/occupational/speech therapy following surgery, acute hospital stay, or physical decline.

Home Health NPI: 1003050089 · Medicare Certified

Call Home Health Intake: (316) 869-0015 →

Refer to Hospice or Palliative

For progressive decline, frequent hospital readmissions, unmanaged symptoms, or patients with a life-limiting diagnosis choosing comfort and dignity in their home or residential setting.

Hospice NPI: 1497968127 · 24/7 Clinical Support

Call Hospice Intake: (316) 869-0015 →

⚡ 24/7 Clinical Intake Queue

Patient Referral Form

Submit patient and clinical details directly to our intake coordinators. Our on-call clinical nurse responds within 1 hour during business days and 24/7 for urgent hospice transitions.

Patient Information

Patient Full Name *

Date of Birth (DOB) *

Patient / Family Phone *

Current Location / Setting *

Patient Address or Facility Room No. Optional

Care Needs & Clinical Timing

Service Requested *

Urgency / Desired Start *

Primary Clinical Diagnosis or Reason for Referral *

Has the patient / family been informed of this referral?

Referring Provider or Facility

Referring Contact Name *

Organization / Hospital / Relationship *

Callback Phone Number *

Callback Email Address * A confirmation receipt will be sent immediately to this email.

Clinical Records & Face-to-Face Orders

Click to choose or drag & drop clinical records Face-to-Face encounter, H&P, demographic sheet, or orders (PDF, DOC, DOCX, JPG, PNG up to 15 MB)

Additional Clinical Notes or Special Instructions Optional

🔒 Information transmitted through this portal is encrypted and processed in strict compliance with HIPAA and HITECH privacy regulations. For immediate life-safety emergencies, call 911.

Prefer paper referral forms? Download and fax orders to (316) 618-0414.

Call On-Call Nurse: (316) 869-0015