Form Center

3. 
6. Lancaster County Office of Aging Referral Form
8. How to Request an Assessment or Services from Office of Aging
   Instructions

   Please follow these instructions for using the online form .
12. Please check one box below and provide all information requested

    1. In home services
    2. Level of care assessment
    3. General inquiry
14. Please do not report concerns about safety ,abuse, neglect , or exploitation using this form. Please note that if you need to report concerns about abuse, neglect, or exploitation, please do so by phone at 717-299-7979, 24 hours a day.
    NOTE: Referrals are processed during agency hours, Monday through Friday 8: 30 am to 5: 00 pm. Referrals are not processed when the agency is closed.
16. Consumer First and Last Name *
    (middle initial if known)
17. Email Address (optional)
19. Home Address*
20. Lives with*
22. City*
23. State*
24. Zip Code*
26. Home Phone Number
    DO NOT USE HYPHENS eg. 7172997979
27. Cell Phone Number
    DO NOT USE HYPHENS eg 7172997979
29. Marital Status
30. DOB*
31. Gender
33. Last 4 digits of Social Security Number (optional)
37. Person Completing Referral *
38. Agency (If Applicable)
40. Phone Number*
41. Email Address*
45. Where is the consumer located?*
46. If at Hospital or NF, expected discharge date
    If at Hospital or NF, expected discharge date

    If at Hospital or NF, expected discharge date
48. Is the consumer alert and oriented?*
49. Is consumer aware of referral?*
50. Consumer's primary language *
52. Who should Office of Aging contact?*
53. Relationship to consumer*
54. Phone and/or email*
56. Is consumer receiving formal services? Please explain*
57. Why is referral being made? What assistance does consumer need?*
61. Please Note: The following are required for placement in a facility.
    Please download forms and send by e mail attachment to aging@co.lancaster.pa.us . Please do not fax. As of 3/23/2020 we are not able to accept faxes.
63. Physician name, address and phone number (optional)
65. PASSR-ID Form
    PASRR-ID
66. Fed Consent Form
    FED Consent
67. Medical-Evaluation-Form-MA-51
    Medical-Evaluation-Form-MA-51
69. Release of Information Form
    Release of Information
73. Financial information if known
75. Consumer's individual monthly income
76. Amount of assets/resources
77. Medical Assistance/ACCESS Card Number (If applicable)
79. Please note that services from Office of Aging are not always free and you may be asked to contribute to the cost of your services depending on your income
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit Submit and Print

* indicates a required field