Referral Form

*We service all adults and teenagers, age 15 to 18

 

*We accept Maryland Medicaid

"*" indicates required fields

Date*
Address
Date of Birth*

Last Used ?*
Route of Administration*
Withdrawal Symptoms?*
Tobacco use in last 30 days?*
Have you participated in medication assisted treatment?*

If Yes.... please complete the next two sections

Medications

Marital Status*
Education Level*
Employment Status*
   

Recommended Services

Education Level*

Terms

Referral Authorizations

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Elevate Health and Wellness. I authorize payment of medical benefits to Elevate Health and Wellness. I also understand that payment of is my responsibility and Elevate Health and Wellness has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Elevate Health and Wellness. I also understand that payment of is my responsibility and Elevate Health and Wellness has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Elevate Health and Wellness. I authorize payment of medical benefits to Elevate Health and Wellness. I also understand that payment of is my responsibility and Elevate Health and Wellness has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

Typing my name below serves as my digital signature.

Referral Authorizations*
This field is for validation purposes and should be left unchanged.

Elevate
Health & Wellness

Contact

Phone# +1 (443) 835-4994
Fax# +1 (443) 869-6615

Email info@elevatehealthwell.com

Address

531 N. Chester St. Ste B Baltimore, Maryland 21205