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QuickStart Care Form
Where are you referring this patient from?
(Required)
Alpaca Health
ARC
Caron, FL
Covenant
Curative
Harbor Health
Heavenly Care
Manor ISD
Memorial Hermann
NAMI
NormanMD
Orange County ISD
Providence NW
Providence SW
Sendero
SIMS
Troy Medical
Not Listed/Other
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Name of your practice, business, or school
(Required)
Is this patient 18 years old or older?
(Required)
Yes
No
Type of care required
(Required)
Therapy Only
Therapy and Meds Management
Meds Management Only
Autism
ADHD
Does patient require a spanish speaking provider?
(Required)
No
Yes
Sendero Program Name
(Required)
IdealCARE
CHAP Expansion
Patient Name
(Required)
First
Last
Patient Date of Birth
(Required)
Month
Day
Year
Patient Mobile Number
(Required)
Patient/Guardian Name
(Required)
First
Last
Parent/Guardian Mobile Number
(Required)
Contact the guardian if the member has an intellectual disability
No
Yes
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Is this a Charlie Health patient?
(Required)
Yes
No
Name of the person from your practice, business or school who is referring the patient
(Required)
First
Last
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Email address of the person at Devoted referring the patient
(Required)
Enter Email
Confirm Email
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Are you a Discharge Planner (DP) or a Referral Coordinator (RC)?
(Required)
DP
RC
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Insurance Carrier
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Insurance Carrier Subscriber ID
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Where are you referring from?
(Required)
Select Clinic
Charlie Health IPO
Charlie Health Overflow
