How to Fill Out and Submit the BAYADA Home Health Referral Form

To refer a patient to BAYADA, you complete a one-page BAYADA home health referral form that captures patient demographics, insurance, clinical orders, and the ordering physician’s signature, then submit it by phone at 888-671-2772, through BAYADA’s online request form, or by fax to the local office. The intake team cannot start work until the form is complete and the required clinical attachments are included, so most of the work is in gathering the right documents before you open the form.

What You Need Before You Start

BAYADA’s referral order form asks for two attachments: a clinical encounter note (or a hospital discharge summary with the history and physical) and a current demographics sheet with a medication list. Alongside those, have the following ready:

Patient demographics: full legal name, date of birth, Social Security number, and current home address. BAYADA routes referrals to the nearest local office based on the address.
Emergency contact or caregiver: name, phone number, and relationship to the patient. If the patient has a healthcare power of attorney or other legal representative, include that contact as well.
Insurance information: primary and secondary carrier names, policy and group numbers, and the payer type (Medicare, Medicaid, Veterans Affairs, workers’ compensation, private commercial, or self-pay). BAYADA accepts all of these.¹
Ordering physician details: name, phone, fax, and the physician’s individual National Provider Identifier. For Medicare, the NPI must belong to the specific ordering physician. A group or organizational NPI will cause the claim to be denied.²
Clinical information: primary diagnosis with ICD-10 code, full medication list with dosages, and a clear description of the services requested (skilled nursing, wound care, physical therapy, speech therapy, occupational therapy, home health aide visits, or a combination).

The clinical encounter note serves a specific federal purpose. For Medicare patients, there must be a face-to-face encounter between the patient and either the certifying physician or an allowed non-physician practitioner no more than 90 days before, or within 30 days after, the start of home health services. The certifying physician must document the date of that encounter and tie it to the primary reason home health is needed. Without that documentation, Medicare will not pay the claim.²

Filling Out the Form Section by Section

The referral order form is a single page split into three parts. The top section is patient demographics and insurance. Fill in every field. A blank address or a missing policy number sends the form back to you before anything happens.

The middle section covers clinical orders. Enter the primary diagnosis and ICD-10 code, attach or transcribe the full medication list, and write out the specific services the physician is ordering. State the frequency of visits the physician wants and any special instructions, such as wound measurement protocols or fall precautions. The resulting plan of care has to specify services, disciplines, frequency, and duration, so the more detail on the original order, the faster the plan gets finalized.²

The bottom section is the physician’s signature. A handwritten signature on a faxed or printed copy is acceptable, as is a secure electronic signature. The order must be signed before submission; an unsigned form cannot be processed.

Pick the Right Service Line

BAYADA organizes care into separate service lines, and the form asks which one applies. Selecting the wrong line delays the referral because intake has to reroute the case. The lines are:

Home health, adult nursing: skilled nursing for adults recovering from surgery, managing chronic conditions, or needing wound care, IV therapy, or medication management.
Home health, assistive care: non-medical help with bathing, dressing, meal preparation, mobility, companionship, and respite for family caregivers.
Pediatrics: skilled nursing and therapy for children with complex medical needs, including ventilator-dependent children and children with developmental disabilities.
Habilitation: support for individuals with intellectual or developmental disabilities, focused on daily living skills and community participation.
Hospice: end-of-life comfort care for a terminal diagnosis, including pain management and family counseling.

If the patient needs more than one type of care, note each one on the form so the intake coordinator can build the right team from the start.

How to Submit the Form

You have three options:

Phone: call 888-671-2772. This is the fastest route for urgent cases, such as a same-day hospital discharge, because you get verbal confirmation that someone is working on the case.
Online: BAYADA’s request-for-services page hosts a web-based referral form. Good for non-urgent referrals when you want a submission record and don’t want to use fax.
Fax: the printed order form has a blank line for the local office fax number. Contact the regional BAYADA office to get the correct number.

For general questions or help locating the nearest office, BAYADA’s main line, 888-253-6197, is staffed around the clock. Whatever channel you choose, protect patient health information. Avoid unsecured email.

Medicare Rules That Shape the Referral

If the patient has Medicare, the referral only produces covered services when three conditions are all met: the patient is homebound, needs part-time or intermittent skilled services, and will receive care from a Medicare-certified home health agency.³

Homebound trips up more referrals than any other criterion. Medicare treats a patient as homebound when leaving home requires considerable effort because of illness or injury, meaning the person needs a wheelchair, walker, cane, special transportation, or another person’s help to get out the door. A patient can still leave for medical appointments, religious services, or occasional short trips without losing homebound status, but the general pattern must be that leaving home is a taxing ordeal or medically inadvisable.³ The clinical documentation on the referral must describe the functional limitations that make leaving home difficult. A note that simply says the patient “needs home health” will not support the claim.

Covered skilled services include nursing care, physical therapy, speech-language pathology, and occupational therapy where there is a continuing need. Medical social services and home health aide visits can be covered, but only in combination with one of the skilled services. They cannot stand alone.² When the patient qualifies, Medicare pays the full cost of covered visits. The only out-of-pocket cost is 20 percent of the Medicare-approved amount for durable medical equipment such as a hospital bed or wheelchair.³

For non-Medicare payers, prior authorization is often required before services begin. Private insurers and Medicare Advantage plans frequently deny authorizations when documentation is incomplete, so the clinical note and medication list carry the same weight as they do for Medicare. BAYADA’s intake team runs a benefits check against the policy and group numbers you provide on the form.

What Happens After You Submit

The intake coordinator verifies coverage and reviews the clinical documentation against the services requested. For straightforward referrals with complete paperwork, this review typically takes 24 to 48 hours. If anything is missing, the coordinator contacts the referring office before the case moves forward.

Federal regulations set the next step. A registered nurse must conduct an initial assessment visit within 48 hours of the referral, within 48 hours of the patient’s return home, or on the physician-ordered start-of-care date, whichever applies. That first visit identifies immediate care needs and, for Medicare patients, confirms homebound status and benefit eligibility. The agency then has up to five calendar days from the start of care to complete a comprehensive assessment, which feeds into the final plan of care signed by the ordering physician.⁴ Regular visits begin once that plan is signed.

Why Referrals Get Rejected

CMS reported that documentation failures accounted for more than half of all improper payments in home health services during the 2024 reporting period, with medical necessity issues adding another third.² At the referral stage, the recurring problems are:

Missing or unsigned physician order. No signature means the form sits in limbo. Electronic signatures count, but the order must be signed before submission.
No face-to-face encounter documentation, or an encounter note that fails to connect the patient’s condition to the need for home health.
Incomplete demographics, especially a missing or wrong address, which keeps the referral from being routed to the correct office.
Group NPI used in place of the individual ordering physician’s NPI, which produces a denied Medicare claim.
Homebound status not supported by the clinical description. The note must spell out the functional limitation that makes leaving home difficult.

Checking those five items before you fax or submit the form saves days of back-and-forth with intake.

If Services Are Later Denied

Separate from the referral itself, the patient has appeal rights if Medicare denies coverage or the agency plans to stop services. The agency must deliver a Notice of Medicare Non-Coverage at least two days before covered services end, and the patient can request a fast appeal through the Beneficiary and Family Centered Care Quality Improvement Organization by noon the day before the listed termination date.⁵ Agencies may also issue an Advance Beneficiary Notice of Noncoverage before providing a service they expect Medicare to deny, in which case the patient agrees in writing to pay out of pocket if Medicare does not cover it.⁶ For non-Medicare patients, appeal procedures are set by the specific insurer and listed on the denial letter.

1
BAYADA Home Health Care. How To Pay
2
Centers for Medicare & Medicaid Services. Home Health Services
3
Medicare.gov. Home Health Services
4
eCFR. 42 CFR 484.55 – Comprehensive Assessment of Patients
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Medicare.gov. Fast Appeals
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Centers for Medicare & Medicaid Services. FFS ABN