Client’s Name: Ability to Pay? Insurance/Private (circle) Birthdate: Telephone Number:
Date of Referral: Address
Referral To: [Service provider’s name, address, and telephone number]
Referred By: [Service provider’s name, address, and telephone number]
Reason for Referral:
Authorization: I,
[Client’s Name], give my permission to
[Service Provider’s Name], to release this information to
[Care Coordination
Provider’s Name]. The information is to be used to assist me in monitoring and coordinating my health care and social service needs.
Signature of client/parent or guardian: Date:
Service Provider’s Reply (summary of findings, diagnosis, recommendations, comments, as appropriate):
Signature: Date: