---
title: Hospital-at-Home Program Referral Form Template | Paperform
description: Professional referral form for primary care to hospital-at-home programs. Streamline acute care at home referrals with remote monitoring setup, mobile nursing coordination, and hospital-level care delivery.
url: "https://paperform.co/templates/hospital-at-home-program-referral-form"
type: static
generatedAt: "2026-03-28T00:44:09.084Z"
---

[← Back to free form templates](/templates/)    ![Hospital-at-Home Program Referral Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/hospital-at-home-program-referral-form.png)
    [Preview](https://_preview.paperform.co/ai-template/hospital-at-home-program-referral-form) [Use this template for free](/create?ai-template=hospital-at-home-program-referral-form)    [Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/) [Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Healthcare Administrator](/templates/role/healthcare-admin/)     About this free form template
### Hospital-at-Home Program Referral Form

This hospital-at-home program referral form is designed for primary care physicians, care coordinators, and healthcare providers who need to refer eligible patients for acute care delivery outside traditional facility settings. As healthcare continues to evolve toward patient-centered, cost-effective models, hospital-at-home programs provide hospital-level care in the comfort of patients' homes through remote monitoring, mobile nursing visits, and coordinated specialist support.

#### Streamline Complex Healthcare Referrals

Referring patients to hospital-at-home programs requires detailed clinical information, care team coordination, and logistical planning. This Paperform template captures all essential information in one organized, professional form—from patient demographics and insurance details to clinical conditions, medication lists, and home environment assessments. Conditional logic ensures you only collect relevant information based on the patient's specific situation, making the referral process faster and more accurate.

#### Built for Healthcare Workflows

Healthcare teams working with hospital-at-home programs, home health agencies, acute care coordinators, and integrated care networks will find this template particularly valuable. The form is structured to meet clinical documentation standards while remaining accessible for busy primary care practices. You can customize fields to match your program's specific admission criteria, add your organization's branding, and integrate submissions directly with your EHR system or care coordination platform using Paperform's healthcare-focused integrations.

#### Automate Referral Processing with Stepper

Once a referral is submitted, **Stepper** (stepper.io) can automatically route the form to appropriate care coordinators, trigger eligibility verification workflows, notify mobile nursing teams, and update your care management systems—all without manual data entry. You can set up automated email notifications to patients and families, schedule initial home assessments, and create task lists for equipment setup and remote monitoring installation.

#### Secure, Compliant Data Collection

Paperform provides SOC 2 Type II compliance and GDPR-ready security features, ensuring patient referral information is handled with appropriate data protection measures. While this solution is not HIPAA compliant, it offers enterprise-grade security suitable for many healthcare coordination workflows. The form supports secure file uploads for medical records, lab results, and imaging reports, keeping all referral documentation in one place.

Whether you're a primary care physician referring patients to innovative care models, a hospital system expanding acute care at home services, or a health plan coordinator managing alternative care pathways, this template helps you deliver coordinated, high-quality care outside traditional hospital walls.
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