Referral Form

Payer Type

Thank you for contacting Divine Agape Health Care Agency.

If the patient/client is enrolled with Gold Coast Health Plan (GCHP), services must be requested and authorized by GCHP before care can begin.

Please complete the GCHP referral form and submit it directly to GCHP:
1) Complete the referral form:
https://res.cloudinary.com/dpmykpsih/raw/upload/gold-coast-site-258/media/r/55055ec96e5b4783b46c535acaac7253/gchp_cs_referral_form_e_mar2024_v2-final_fillable2p.pdf

2) Submit the completed form to GCHP:
Email: calaim@goldcoasthealthplan.org
Fax: 1‑855‑883‑1552

Once GCHP reviews and authorizes services, they will coordinate provider selection. You may request Divine Agape Health Care Agency as your provider at that time by filling out "Additional Comments".

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Services