Please Note! This referral is not considered received by MAHEC until you receive a confirmation number after clicking the submit button.

Who is submitting this referral? If you are referring yourself or a family member, please select "Self/Family Member."
What agency is sending this referral? Please include a contact name and phone number.

If insured, this must match first name on insurance, otherwise first name on identification if it differs from the name the patient goes by

Please type in any patient insurance information. Please type "NA" if none or unknown.

Please briefly describe the primary reason(s) that the patient is requesting services. Please note that if the patient becomes a MAHEC client, this description will be included in the referral that is saved to the patient’s chart.

Please attach additional patient documentation to this request form or fax to (828) 333-5465.
Up to 10 files may be uploaded.
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