CARES Patient Referral Form

Referral Source Information
Provider Name
Clinic/Hospital Name
Phone Number

Area CodePhone Number
Email
example@example.com

Are you submitting a referral for one or multiple patients?

Minor Information
Caregiver Name
Caregiver Alternate Phone Number

Area CodePhone Number

PLEASE PROVIDE DOCUMENTATION

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For more information on Central California Asthma Collaborative (CCAC) and/or the Comprehensive Asthma Remediation and Education Services (CARES) Program contact 1-833-MYASTHMA (692-7846) or visit our website www.ccaccares.org

To ensure compliance with HIPAA regulations and streamline the referral process for multiple patients, a Healthcare Partnership Specialist will contact you within 3–5 business days. For urgent referrals, please call (559) 939-6320.

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