Connections | Provider Referral Form

Community Health Workers are bridging health and social services to community members. Facilitating access to services and improving the delivery of high-quality services in order to overcome health barriers.

Referring Provider Information
Name of Referring Person/Provider Name of Referring Person/Provider * First Last
Referring Organization (if applicable)
Type of Referring Organization
Organization Phone Organization Phone - ### - ### ####
Provider Email
Information for Person Being Referred
Name Name * First Last
Date of Birth Date of Birth / MM / DD YYYY
County *

County Barry Eaton Other Other
Insurance Information

Please provide all insurance information. Insurance will not be billed without prior consent of the client.
Name of Policy Holder
Policy Holder Date of Birth Policy Holder Date of Birth / MM / DD YYYY
Name of Insurance Company *

If unknown or uninsured, type "unknown"
Policy Number *

If unknown or uninsured, type "unknown"
Group Number *

If unknown or uninsured, type "unknown"
Preferred Method of Contact

Please provide at least one method of contact
Preferred method of contact *

Preferred method of contact Phone Call Text Email Letter
Phone/Text Phone/Text - ### - ### ####
Email
Address for Letter Address for Letter
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Select All Reason(s) for Inquiry *

Select All Reason(s) for Inquiry Food Assistance Housing / Utilities Assistance Healthcare Coverage Assistance Substance Use / Harm Reduction Services Medical Care / Mental Health Services Social Services Assistance Transportation Assistance Employment Assistance Other Other

Select ALL options you are needing additional information on.
Does the client require a translator be present during the upcoming visit provided by the health department? If yes, please specify primary spoken language.
Does the client require accommodations provided by the health department? If yes, please mention them below.
Please include any additional information you wish to provide.
Maximum of 500 characters allowed. Currently Entered: 0 characters.

Connections | Provider Referral Form

Connections | Provider Referral Form

Referring Provider Information

Information for Person Being Referred

Insurance Information

Preferred Method of Contact