You can always press Enter⏎ to continue
Health Connect America Referral Form
Please complete all fields.
9
Questions
START
HIPAA
Compliance
1
Health Connect America Employee Contact Information
*
This field is required.
How can we reach you, the person making the referral?
Name
Office phone number
Health Connect America Location
Previous
Next
Submit
Press
Enter
2
Patient demographic information
*
This field is required.
Patient Name
Mobile number
Email
Social Security Number (This form is end-to-end encrypted and HIPAA compliant.)
Date of birth
Address
Previous
Next
Submit
Press
Enter
3
Gender
*
This field is required.
Male
Female
Other
Previous
Next
Submit
Press
Enter
4
Pregnant?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
5
Is this patient in IOP?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
6
Does the patient require an immediate visit with a Cedar Recovery provider?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
7
Insurance information
*
This field is required.
Insurance provider
Policy Number
Effective date
Previous
Next
Submit
Press
Enter
8
Brief explanation of reason for referral:
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
9
Other relevant information
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
9
See All
Go Back
Submit