HMH Referral Form

Harmony Mental Health Inc.

Thank you, for choosing us as your pathway to Harmony.
Date

MonthDayYear
Is this referral for a Minor or Adult?*

MinorAdult
Referral Source *
Access Code
Pre-assigned Access code. HMH Employee Only
How did you hear about us? *
At any time during this process you may save your progress by selecting "save." At which point you will be prompted to create an account & provide your email address. A link to this referral will be emailed to you. However, if you do not have an active email address, we do suggest that you complete this referral in one of our 3 office locations or call-in to have our referrals team assist you in your submission.

Harmony Referral Disclosure

Please read carefully prior to agreeing to the terms and conditions

Parent &/or Legal Guardian
Parent/Guardian Name #1 *

First NameLast Name
Relationship to Client *
Parent/Guardians legal relationship to the prospective client
Parent/Guardian Name #2

First NameLast Name
Relationship to Client
Parent/Guardians legal relationship to the prospective client
Has the minor ever been the subject of a custody agreement, adoption or have any other custody or guardianship changes occurred?*

YesNoNot to my knowledge
Types of Custody/Guardianship*

Legal CustodyPhysical CustodySole CustodyJoint CustodyIn-States Custody
Notes on Custody/Guardianship
Please provide any additional custody or guardianship information here.

Insurance & Billing Information
What resources are available to pay for services?*

InsuranceDHHR: Requires Special Billing LetterMedicaid/MCOSelf-Pay
Manage Care Organization (MCO)
Medicaid
Medicaid #
THP number starts with an H
Insurance Company
These are the insurances we can bill.
Insured Name *

First NameLast Name
Insured DOB*
Insured SSN# *
Group # *
Policy # *
Provider Customer Service Phone #*
Provider # is located on the back of the insurance card.

Before you go...

Please review and make any necessary edits to your referral. Please utilize the checklist below to determine what documents are REQUIRED for submission of this form. Finally, please take a moment to read and sign the below statement of confirmation.
UPLOADING CHECKLIST Any Pre-marked submission items are required to be uploaded before submission. Please select any additional items you will include in your submission.*

ID (Front/Back)Insurance (Front/Back)Social Security CardGuardianship Agreements /OrdersExternal Referral DocumentsSpecial Billing LetterMedicaid ID CardOther
Upload Necessary Documentation Here *

Please convert images/screenshots to small JPEG format before submitting. Additionally, consider combining and uploading documents as one PDF attachment. You can only upload up 5GB of data and/or 10 files per submission. Any documents you are unable to upload please email to ref1@harmonymh.org and in subject line please include referral ID # provided upon submission.
Cancelof
I Your Name * confirm that I have the legal right or received consent from the referred or their parent/guardian to make this referral. To my knowledge all information that has been provided is both accurate and within my right to release.
Referral Source Signature *

Clear

SUBMIT REFERRAL
IMPORTANT

Once you select "Submit" please DO NOT refresh or close your browser page until you have been redirected to the confirmation page. Please understand that if by any chance you do refresh or close the browser the referral may duplicate or become corrupted only providing partial information, this may result in a processing delay of the referral.
Please verify that you are human*
Should be Empty:

Prospective Client Info.	Parent &/or Legal Guardian Info.
Full Name	Full Name
Demographic Info.	Proof of Custody &/or Guardianship
SSN #	Address & Contact Info
Insurance card	Formal ID
Prior Treatment History

Harmony Mental Health Inc.