Thank you for using the Zócalo Health referral form. Please provide as much information as possible to help us ensure timely and effective outreach to the patient. If you have any questions, feel free to contact us at (213) 855-3465. Our office is open Monday through Friday, from 8:00 AM to 5:00 PM (PST).
Patient Information
Patient's Full Name
*
First Name
Last Name
Patient's Phone Number
*
Please enter a valid phone number.
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Email
example@example.com
Patient's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the patient a Medi-Cal Member?
*
Please Select
Yes
No
Unknown
If yes, patient’s Medi-Cal ID #
Patient's Health Plan
Please Select
Santa Clara Family Health Plan
Central California Alliance for Health
Blue Shield of California
Anthem
Inland Empire Health Plan
Contra Costa Health
HealthNet
Other
Health Plan Member ID #
Patient's Preferred Language
*
Ex. Spanish
Reason for Referral
*
Please provide a brief narrative describing the patient’s circumstances and the reason for the referral
Which program are you referring the patient to?
*
Clinical Services (For medical visits with a primary care provider, urgent care, or chronic condition management.)
Behavioral Health Services (For therapy, counseling, or support with mental health or substance use needs.)
Enhanced Care Management (For patients with complex health or social needs who need extra help coordinating care across providers and services.)
Community Supports (For help with non-medical needs like food, housing, transportation, or other social services.)
CHW Benefit (For support from a Community Health Worker who can connect patients to resources, provide health education, and offer ongoing guidance.)
Unsure (If you’re not sure, choose this option and our team will direct the patient to the right program.)
Type of Referral
*
Please Select
Urgent (requires immediate follow up within 24/hrs or less)
Routine (follow up within 1-2 business days)
Is the patient currently admitted, discharging or transitioning from an emergency room or inpatient hospital stay?
*
Please Select
Yes
No
If yes, please select the patient’s status
*
Please Select
Admitted
Discharging
Transitioning
N/A
Back
Next
Referring Entity Information
Referring Entity
*
Please Select
Hospital
Clinic
Community Organization
Internal (Zócalo Health employee)
If this is an internal referral from a Zócalo Health employee and the patient is already established with us, please include the patient’s Fold account link below.
Name of Contact Responsible for Referral
*
First Name
Last Name
Contact Phone Number
*
Please list a valid phone number.
Contact Email Address
example@example.com
Contact Relationship to Patient
Please Select
Discharge Staff
Case Worker
Clinician
Community Organization Staff
Other
Optional For Healthcare Provider : Please upload any clinical notes or medical documentation here:
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