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Lancaster County Office of Aging Referral Form

  1. Lancaster county office of aging

  2. Lancaster County Office of Aging Referral Form

  3. Please check one box below and provide all information requested

  4. 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.

  5. (middle initial if known)

  6. DO NOT USE HYPHENS eg. 7172997979

  7. DO NOT USE HYPHENS eg 7172997979

  8. 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.

  9. Financial information if known

  10. 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

  11. Leave This Blank:

  12. This field is not part of the form submission.