Online Referral Form » LifeCare Alliance

Referral Form
1699 W. Mound St.
Columbus, OH 43223
Phone: 614-278-3141
Fax: 614-278-3143
Email: referral@lifecarealliance.org
What is the source of this referral?*
- Referring Agency
- Physician's Office
- Self
- Family
Your Email Address*

Referring Agency
Name of Referring Agency*
Name of Agency Representative Making Referral*
Phone*
Email*
As the Referring Agency representative, I have communicated the service basics and referral process for the identified LifeCare Alliance services to the patient.*
- Yes
- No
The patient referenced on this form agrees to proceed with the assessment process for the identified service(s).*
- Yes
- No
If you answered no to either #1 or #2 above, provide background information so that we may proceed with initiating service:

Patient Medical History
ICD Diagnosis Code(s)
Complete the fields below for Diabetic or Nutritional Counseling only
Most Recent A1C Results
Date of A1C Test
Is Information on Labs and Medications Available for This Client?
LifeCare Alliance will follow up with referring agency for this information.
- Yes
- No

Your referral submission is almost complete. Please follow any instructions in the reCAPTCHA field below, then click Submit. If you have any questions or concerns about this process, please contact our Customer Service Department at 614-278-3130.

Referral Form