LHC Provider Referral Form

Provider Referral Form

Please contact us with any questions at 541-485-6340
REFERRAL ELIGIBILITY

*READ FIRST*

Due to HIPAA regulations, we are unable to accept referrals from providers under either of the following scenarios:
- The provider does not fall under the Continuity of Care rule or
- The referring provider cannot verify the individual has consented to the referral.
If your organization does not align with one of the following types listed below or the individual has not consented to the referral, do not continue with this form. Instead, please assist the individual in completing our Self-Referral Form.

If you consider the referral to be needed urgently, please do not use this form. Instead, contact us directly.
Type of Referring Organization for Continuity of Care*

Behavioral Health ProviderCoordinated Care OrganizationHospitalAcute Care or Emergency DepartmentPeer Support ProgramCrisis CenterPrimary Care Provider or Medical HomeSubstance Use Provider
Has the individual provided verbal consent to this referral?*

I verify that the individual has provided verbal consent to this referral.

CONSENT FOR FOLLOW-UP WITH INDIVIDUAL

To ensure privacy, Laurel Hill Center requires verification of an individual's consent to be contacted prior to outreach.

If you are unsure if the individual gives consent for Laurel Hill Center to identify, select Save, confirm with the individual and then return to complete your form.

Please Note: Without consent to LHC identification, follow-up on the referral may be delayed.
Consent for LHC's identification through email*

YesNo
Consent for LHC's identification through voicemail*

YesNo
Since the individual does not consent to LHC being identified through voicemail, please follow these important steps after submitting your referral:

1) We will contact you to confirm the referral has been received

2) The referral will be assigned an expiration date (28 days from referral submission date).

3) You will need to let the referred individual know that they will need to call our main office before the expiration date during the business hours of 8am-5pm, Monday-Friday at (541) 485-6340.

4) If the individual has not contacted us by the expiration date, the original referral will be expunged.

REFERRER INFORMATION
Date of Referral

MonthDayYear
Date
Referring Provider Agency/Clinic*
Name of Person Completing Referral *
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Preferred Method of Follow-up

EmailPhoneFax