Outpatient Medication Assisted Treatment Referral Form
Date of Referral
-
Month
-
Day
Year
Date
Have you ever been in Treatment?
Yes
No
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Primary Phone or Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Good time to reach you
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Physician
Primary Insurance
ID#
Subscriber
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Secondary Insurance
ID#
Subscriber
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Medication Names and Dosage
Visit Reason
Self-Referral
Inpatient follow-up for Maintenance
Other, please specify below
Please fax all information to 810-648-6183 Attention of MAT Clinic
Submit
Should be Empty: