Discharge Planning Facilities & Agencies Form

SNFs & Home Health Agencies: After review, we will add you to the list of providers we distribute to patients who request that service. This list is updated quarterly. Other Healthcare Providers: After review, we will keep your information for when there is a vacancy on the list of providers we distribute to patients who request the services you offer.

Huntington Hospital employees do not endorse nor recommend any one provider to our patients and families.

* Required field
* Facility/Agency Name:
* Address:
* City:
* State:	Please select state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
* Zip Code:
Service Areas Covered:
* Contact Email:
* Phone Number:
Fax Number:
Business License #:
Payors Accepted:    (if applicable)
Types of Services Provided:
Please choose a minimum of one from the following list:	SNF Certified Home Health Agency Home Care Agency (Independent Contractors) Home Care Agency (Employees) DME RCFE Hospice Other discharge facilities and agencies
Program Details: (Please list any services or credentials you offer, e.g., languages spoken, accreditation, licensing, certification):