Become a Foster Parent

Online Referral Form

Online ReferralsOur Online Referral system is a secured, HIPAA compliant system that will let you send a secure online referral to the Health Connect America office in question. Anything that is marked with a red asterisk is required.


Before submitting your referral, you will have a chance to review it at the very end. The referral will be sent to the office in question and the staff in that particular office will follow up with you.


If you are having difficulty using the online referral form or have any questions on how it works or its security, submit a website inquiry on our contact us form page. IT staff will follow up with you regarding your inquiry.

If you prefer to fax your referral, click here to do a PDF referral.

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    Region
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    Referring Agency
  • 3
    Client Information
  • 4
    Additional Questions
  • 5
    Insurance Information
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    Preview
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    Complete
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