Eskenazi Senior Services Referral Form
Fill out this form to refer a patient for CICOA options counseling and services.
As a Healthcare Collaborations partner, our embedded Options Counselor at your site will be notified of referrals submitted through this form and can begin the process immediately.
After successfully submitting the form, you will see a green confirmation message and receive a confirmation email.
*The referral form requests information that is privileged and confidential, including patient information protected by federal and state privacy laws. We use security measures on our website to protect against the loss, misuse and alteration of data used by our system. CICOA Aging & In-Home Solutions will not share, sell, rent or distribute personal information with anyone without your permission or unless ordered by a court of law. Information submitted to us is available only to employees managing this information for purposes of contacting you and assessing eligibility for services.