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QuickStart Care Form
Where are you referring this patient from?
(Required)
Ascension Providence Waco
Alpaca Health
Austin Area Ob/Gyn (AAOBGYN)
Austin Diagnostic Clinic (ADC)
Austin Geriatric Specialists (AGS)
Austin Regional Clinic (ARC)
Capital Medical Clinic
Charlie Health
Children's Clinic of Lufkin (CCLufkin)
Conroe ISD
Conviva Care Centers
Covenant Health System
Curative
Curative Primary Care
Cypress Physicians Association
Devoted Health
Diagnostic Clinic of Longview (DCOL)
First Primary Care
HAAM
Hamilton Health Box
Harbor Health
HCA
Heavenly Care
HEB
Laredo Health Department
Manor ISD
Memorial Hermann Pediatrics
Millennium Physician Group
NAMI
Next Level Prime or Urgent Care
Nexus Psychiatry
NOCD
Norman MD
Optum
Orange County ISD
PCP For Life
People One Health
Piedmont Pediatrics
Premier Family Physicians (PFP)
Providence WA, Northwest
Providence WA, Southwest
Rooted Rhythm Therapy & Madrega Wellness
Sendero Health Plans
Silverlake Pediatric Clinic
SIMS
Troy ISD
Troy Medical
Vancouver Clinic
Victory Medical
Village MD
WellMed
Other / Not Listed
Myself
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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
