Referral Form
Please fill in the form below
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Patient Contact & Insurance Information
Patient Contact Number:
*
Patient's E-mail
example@example.com
Type of Insurance Plan:
*
Commercial/Private
Medicare
AHCCCS
Self Pay
Other
Commercial
Aetna
Blue Cross Blue Shield (BCBS)
Cigna
Aetna
Other
AHCCCS (Medicaid Plans)
Arizona Complete Health- Complete Care Plan
Banner UniversityHealth Plans
Care1st Health PlanArizona
Health ChoiceArizona
Molina CompleteCare of Arizona
Mercy Care
UnitedHealthcareCommunity Plan
American Indian Health
Member ID #:
*
Write "Self" if patient doesn't have insurance
Reason for Referral?
Please select all that apply:
*
Primary Care
MAT/Substance Use Disorder
Psych
ADOT Forms
Peer Support
Other
Current Therapist Information
Current Therapist?
*
Yes
No
Referral Information
Name of Person Referring
*
First Name
Last Name
Company/Facility
*
Referring Person Email
*
example@example.com
Referring Person Phone Number
*
Example: (000) 000-0000
Referring Person Phone Extension
If applicable
Case Manager/CO3/Therapist Name
Case Manager/CO3/Therapist Email
example@example.com
Case Manager/CO3/Therapist Phone Number
Example: (000) 000-0000
Case Manager/CO3/Therapist Phone Extension
If applicable
Who should receive scheduling communication regarding this referral?
*
Patient
Case Manager/CO3/Therapist
Referring Person
Other
Preferred Communication Method?
*
Email
Phone
Is Patient currently inpatient, incarcerated, or hospitalized?
*
Yes
No
Estimated Release Date
-
Month
-
Day
Year
Date
Is the patient being referred justice involved?
Yes; DoC (Parole)
Yes; County Corrections (Probation)
No
Do you have a signed ROI?
Yes
No
Upload ROI
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Upload Discharge Summary or Patient Demographics
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