Use the form below to refer someone who is covered by a Medicaid Waiver

(i.e. Home and Community Based Services)

This form is HIPAA Compliant. Call 952-562-1235 with any questions.

NPI# 1881253037
FAX: 844-999-1534
Email: referrals@healthemed.net

We will let you know the referral was received and then work to get the services approved and/or coordinate shipping and remote setup. When the device is shipped or notifications have been set up we will follow up with you again to let you know. Thank you for the referral!

  • Your Information:

  • Waiver Case Manager / Waiver Care Coordinator Information

    Please provide contact information for the person who will approve services if requesting through the Medicaid Waivers
  • Price: $0.00 Quantity:
    Agreed upon county/state pricing
  • Client Information

    Please provide information for the person who will be receiving the product.
  • Caregiver

    This will be the person we contact to help arrange the delivery and setup of our services
  • Additional Notes