MAHEC Forms

Referring Agency

What agency is sending this referral? Please include a contact name and phone number.

First Name

Last Name

Middle Initial

Date of Birth

Assigned Sex at Birth

Preferred Name (Optional)

Preferred Pronouns (Optional)

Current MAHEC Patient? (Optional)

Please select all departments you currently see at MAHEC

Race

Ethnicity

Primary Language

Language Spoken at Home

Insurance

Please type in any insurance information you may have for the patient. Please type "NA" if none or unknown.

Parent or Guardian Name

Phone

Street Address

Apt, suite, unit or floor #

City

State

Zip

Reason

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.

Alternate Phone to above Parent/Guardian contact phone

School

Please fax additional patient documentation related to this referral to 828-333-5465

1 Referring Source

2 Patient Information

3 Insurance Information

4 Contact Information

5 Referral Details

6 Additional Referral Details