Referral Form
Blossom and Florish LLC accepts Maryland Medicaid and Services Ages 15 and up
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Worker Name
*
Referring Workers Phone
*
Referring Workers Fax Number
Referring Workers Email Address
*
Drug of Choice
*
Date of Last Use
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How Often?
*
How Much?
*
(ex. $10 worth, 2 12oz Beers, etc..)
Route of Administration
*
Oral
Inhalation
Injection
Longest Period of Abstinence?
*
Withdrawal Symptoms
*
Yes
No
Tobacco use in last 30 days?
*
Yes
No
Have you participated in medication assisted treatment? If Yes.... please complete the next two sections
*
Yes
No
Medications
Suboxone
Methadone
Other
Program / Facility / Location
Marital Status
*
Single
Married
Divorced
Widowed
Number of Dependent Children?
*
Physical Disabilities
*
(ex. Difficulty hearing, speaking, walking, etc..)
Medical Challenges
*
Highest Education Level
*
Grade School
HS/GED
College
Employment Status
*
Employed
Unemployed
Self-Employed
Recommended Services
Recommended Service Level
*
Substance Abuse Evaluation-Consists of one 2hr. session.
Outpatient Treatment - 12-18 week program (6-8 hours per week) for adults. Random Drug Testing, individual, group, and self-help meeting attendance is required.
Intensive Outpatient–12-24 week intensive program (9-12 hours per week) for adults. Individual, group, and self-help meeting attendance is required. Random Drug Testing required.
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Terms
Referral Authorization
I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Blossom and Florish LLC. I authorize payment of medical benefits to Blossom and Florish LLC . I also understand that payment of is my responsibility and Blossom and Florish LLC has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Blossom and Florish LLC. I authorize payment of medical benefits to Blossom and Florish LLC. I also understand that payment of is my responsibility and Blossom and Florish LLC has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Blossom and Florish LLC. I authorize payment of medical benefits to Blossom and Florish LLC. I also understand that payment of is my responsibility and Blossom and Florish LLC has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.
Referral Authorizations
*
I agree to the terms of the referral authorization
Signature
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