Program Referral Form
Please fill out the HIPAA-compliant form below if you would like to refer a patient to our wellness programs or services. If you have questions, please contact Martine Rocker at (334) 293-6502.
Patient Information
Patient Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Email Address (if available)
Example: johndoe@gmail.com
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender Identity
*
Male
Female
Transgender
Non-binary/non-conforming
Prefer not to respond
Patient's Employer:
*
Preferred method of contact:
*
Phone
Email
Text
Preferred time to contact:
*
Morning
Afternoon
Evening
Other
What type of health insurance does the patient have?
*
None
Medicaid
Medicare
Private
Other
What type of chronic disease(s) does the patient have? (select all that apply)
*
High Blood Pressure
Diabetes
Obesity
Cancer
Chronic Obstructive Pulmonary Disease (COPD)
Arthritis
Mental Condition (Depression, Schizophrenia, Bipolar, etc.)
Asthma
Other
None
What program(s) or services are you referring this patient to?
*
National Diabetes Prevention Program:
for patients with prediabetes, a lifestyle change program that prevents or delays the development of type 2 diabetes.
Diabetes Self-Management Support Program:
for patients with type 2 diabetes, a program that teaches techniques to deal with symptoms
Chronic Disease Self-Management Program:
for patients with chronic health issues, this program provides effective tools to manage and prevent chronic health conditions
HeartLink:
for patients who would like to learn how to manage and prevent chronic health issues such as cardiovascular disease, diabetes, hypertension, arthritis, and more
Wellness Case Management:
for patients with a chronic health condition and little or no health insurance, this program helps patients find a doctor and connects them with medications and other services
Other
Patient's hemoglobin A1C
*
Patient's fasting plasma glucose
*
Patient's blood pressure
*
Healthcare Provider Information
Physician/NP/PA Name
*
First Name
Last Name
Practice Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Email
*
example@example.com
Please include any other information that will help us assist this patient.
Signature
*
Submit
Should be Empty: