A A A
Call Toll-Free
1-855-567-0252

Providers: Use this HIPAA-compliant form to refer your patient to community service

Provider Information

Provider Name:*

Clinic/Agency Name:*

Provider Phone number:*

Provider Email address:*

Please enter contact information for your patient and/or the patients alternate contact.

Patient Information

Last Name:

First Name:
Date of Birth:
Phone number:

Email address:
Address:

County: *

Alternate Contact

Last Name:

First Name:
Phone number:

Email address:

County:

Please indicate concerns you have regarding your patients current situation. Select all that apply or use comment box below to elaborate or indicate a concern not included on this list:


COMMENTS:

Optional Questions

Does this patient have chronic pain?
Is this patient homebound?
Is this patient already a Medicaid client?
Do you have other concerns or needs for this patient?
Would you like to us to contact you for more information?

Note: Not all services may be available in all areas.



Note: * is a required field

Connect with Your Local CLC.

Washington’s Community Living Connections staff are available to help you explore your options to meet your current needs or create a plan for the future.

Connect now
Disclaimer
Privacy
Contact
Call Toll-Free
1-855-567-0252
Staff Login
by RTZ Systems