In-Home Care Referral

If you would like to refer a patient for home care services, simply complete the form below and an Amity representative will contact you as soon as possible. In most instances, we are able to open new cases within 24-hours. 

If you would like more information about our services without making a referral, go to Contact Us and complete the form. We appreciate your trust in Amity Care and look forward to serving you! 










How would you like to be notified about the status of your referral? Telephone Email









Patient's Payer Source (check off primary)




Which services does the patient need? (check all that apply)