Make a Referral - 2 Easy Steps

1. Complete form. Complete form below to make a formal referral as a potential client at Hiawatha HomeCare.

2. We will contact you. One of our intake representatives will contact you on the next business day.

If this is an urgent need, please contact us at 800-837-8898 - during business hours ask to speak with intake; after business hours, please ask to speak with the on-call nurse.

  • MM slash DD slash YYYY
  • If uncomfortable using full names please use initials of the individual.
  • Please share at a minimum City and State that the client will be residing in at the time requiring cares.
  • MM slash DD slash YYYY
  • Please indicate all sources of insurance available to the client. We will obtain identification numbers upon follow up to this inquiry.