Axescare manages 5 data types including clients. Helps you organize, track, and share your work in 1 place for teams and solo users.

24/7 Submission HIPAA Secure

Available 24/7

Refer a Patient

Hospitals, physicians, SNFs, case managers, and families can submit referrals anytime. Manha AI begins processing the moment you click submit.

~6 min response

Average intake time

HIPAA Secure

Encrypted & compliant

AI + Human

Reviewed by real staff

Your Information (Referral Source)

I am a *

Organization / Facility

Your Name *

Phone

Patient Information

Patient Full Name *

Date of Birth

Phone

Address

City

State

ZIP

Insurance Information

Payer / Insurance

Policy Number

Authorization #

Medicaid #

Medicare #

Clinical Information

Diagnosis / ICD-10 Codes

Hospital Discharge Date

Service Requested

Requested Start of Care

Reason for Referral *

Referring Physician

Physician Name *

NPI

Phone

Fax

Attach Documents (Optional)

Upload face sheets, insurance cards, medication lists, discharge summaries, or face-to-face documentation.

Upload document (PDF, image, or Word)

Drop file here or browse

.jpg, .jpeg, .png, .pdf, .docx · Max 10MB

Additional Notes

By submitting, you confirm you are authorized to share this patient's information for care coordination purposes. All data is transmitted securely and handled in compliance with HIPAA regulations.