Referral Form

Use the form below to refer someone who is covered by a Medicaid Waiver

(i.e. Home and Community Based Services)

I am a * Referrer First Name * Referrer Last Name * Referrer Phone Number * Referrer Email * Referrer Organization

Waiver Case Manager / Waiver Case Coordinator Information

Please provide contact information for the person who will approve services if requesting through the Medicaid Waivers

Case Manager First Name Case Manager Last Name Case Manager Phone Case Manager Email Case Manager Organization

Client Information

Please provide information for the person who will be receiving the product.

Client First Name * Client Last Name * Client Date of Birth * MM-dd-yyyy Client Primary Language Spoken Client Secondary Language Spoken Client Phone Number Client Email PMI / Member / Subscriber ID # Waiver Categories * Address * Street Address City State/Region/Province Postal / Zip Code County

Additional Information

Who should we contact to set up Services?

This will be the person we contact to help arrange the delivery and setup of our Services.

Contact First Name Contact First Last Contact Phone Number Contact Email Additional Notes

What else would you like us to know about the Client or Referral?

How did you hear about us? *

Thank you for the referral information. After submitting the form:

We will contact you to confirm the referral was received.
We will contact the person responsible for approval/filling medications to confirm services/setup.
We will follow up with you after everything is set up. Thank you for the referral!

If you prefer you may download and print a copy of this form here

This form is HIPAA Compliant. Call 952-562-1235 with any questions.

NPI# 1881253037
FAX: 844-999-1534
Email: enrollment@healthemed.com