Provider Referral Form

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. 

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.