Recovery Center Referral Form

Recovery Center Referral Form

Medication-Assisted Treatment (MAT) services
Patient Full Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is the Patient Insured?
Is the Patient enrolled or eligible for Medicare/Medicaid?
Policy Holder’s Name

First NameLast Name
Policy Holder’s DOB

MonthDayYear
Date
Relationship to Patient
Medical Insurance
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Policy ID
Group #
Recovery Center Information
Provider Name

First NameLast Name
Prescriber DEA (if control)
Provider Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
example@example.com
Medication Requested:

Other
Requested Injection Date:

MonthDayYear
Date
Last Dose Date:

MonthDayYear
Date
Transportation Arranged
Dr. Aziz Healthcare Solution,

Phone: 317-842-5771, Fax: 317-576-1394, Email: clinic@drazizrx.com
Address: 7320 E. 82nd St., Indianapolis, IN 46256
Naeem Baig Clinic Manager Mobile: (317) 678-9353
Additional Notes or Instructions
Should be Empty:

Recovery Center Information