Online Referral Form

Consumer First name

Consumer Last name

Email

Address

Phone

Alternative Phone Number

Does the Consumer have a legal guardian?

Yes

No

Consumer's SSN

Consumer's DOB

Month

Day

Year

Maryland Medicaid/Medical Assistance

Yes

No

Are they current enrolled in MTS/ACT, Targeted Case Management, Mental health Residential Treatment Center, Residential Substance Use Disorder Treatment, Substance Use Disorder Intensive Outpatient, Substance Use Disorder Partial Hospitalization Program,

Yes

No

Unknown

Current Behavioral Health Diagnoses and Medication Information

Primary Diagnosis (DSM-5 or ICD-10 code & name)

Secondary Diagnosis (if applicable):

Current Medication List:

Diagnosis Source, Name, Credentials & Date

Presenting Problems, Current Symptoms & Needs

Why is PRP being recommended in addition to outpatient mental health treatment/modalities? This section is mandatory from the provider for PRP eligibility. Briefly describe the individuals current problems, symptoms, and needs for community support.

Drugs and/or Alcohol

Services Needed:

Supportive Services (PRP) in Baltimore, Maryland

Therapy Solutions for Anxiety and Depression in Baltimore, Maryland

Psychiatric and Medication Management Services in Baltimore, Maryland

Substance Abuse Therapy and DUI Classes in Baltimore, Maryland

Referring Provider Information

Referral Source type

Other (please specify)

How did you hear about us?

Referral First, Last Name and Credentials

Licensure Status for Referral Review

Your Company

NPI Number with Active Medicaid

Address

Referral Phone

Fax number

Referral Email

Supervisor Name and Credentials

Supervisor Email

Certification and Signature

Please review the information above, certify its accuracy, and sign below.

Please acknowledge

I certify that I am the referring provider or authorized representative and that the information provided is accurate to the best of my knowledge. I understand that my electronic signature will be recorded along with a system-generated date and time.

Signature

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Date and time

Month

Day

Year

Time

HoursMinutes

All information submitted on this form, including file attachments, meet or exceed confidentiality provisions of the Health General Article of the Maryland Annotated Code, HIPAA regulations and Title 42 C.F.R.

1826 Woodlawn Drive

Suite 3 & 4

Gwynn Oak, MD 21207

Office Phone:

410-800-2121

Emergency 24 hour number:

443-938-9944

Crisis Hotline:

Call 988

Email: admin@beautifulheartsandminds.org

Refer your client to us!

If you are active Medical professional, Therapist, and/or Psychiatrist please fill out this form.

Online Referral Form

Current Behavioral Health Diagnoses and Medication Information

Presenting Problems, Current Symptoms & Needs

Referring Provider Information

Certification and Signature