(952) 898-4237
Referral Intake · A Team Member Will Respond

Refer a Client to
Triple N Home Health Care

Triple N accepts referrals from hospitals, clinic discharge planners, county social services, and managed care organizations. A team member will respond and work efficiently to get your client's care started.

Referral Form

Submit a Client Referral

Download our referral form to get started. Questions? Call (952) 898-4237. A team member will respond.

Download Referral Form (PDF) →
Client Referral Form
Please fill out with as much detail as possible. All submissions are confidential.
Select Service Type

Check all that apply.

Individual’s Information
Sex
Waiver Type / Payment Source

Check all that apply.

Are Medical Assistance and the waiver currently active?
Guardianship Status
Case Manager Information

Please note: Along with this form, we ask that you return a copy of the most current Coordinated Service and Support Plan.

Client information is kept strictly confidential and used only to coordinate care.

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