NEHS – Website – Intake Team Referral Lander

Please complete the form below with the information about yourself and details about the client/patient you are referring
Referring Organization Name*
Referring Organization Contact Person
Referring Organization Phone
Please enter a valid phone number.
Referring Organization Email
example@example.com
First time referring?*

YesNo
Client Information
Is this request urgent?*

NoYes
If urgent, please indicate criteria that makes the referral urgent
Name of Client (as it appears on insurance card)*

First NameLast Name
If client is under 18, guardian name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Language
Preferred Clinic*
Insurance Plan
Insurance Plan ID #
Secondary Insurance (if applicable)
Secondary Insurance Plan ID #
Reason for referral (symptoms and treatment needs)
Requested Services
Preferences

TelehealthIn-Person
Preferred time of appointment

MorningAfternoonEvening
PCP Name
Hospital discharge?

YesNo
Current medications
Medical Records

Cancelof
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Client Information