MAHEC Forms

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

Referring Agency

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

Referring Agency Provider (or contact name)

Referring Agency Phone

Referring Agency Fax

Referring Agency Email

Legal First Name

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

Legal Last Name

Middle Initial

Date of Birth

Assigned Sex at Birth

First Name Patient Goes By (if different than Legal First Name)

Pronouns

Race

Ethnicity

Primary Language

Language Spoken at Home

Insurance

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

Parent or Legal Guardian Name

Email Address

Phone

Alternate Phone

Street Address

Apt, suite, unit or floor #

City

State

Zip Code

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.

School

Current Grade

Please attach additional patient documentation to this request form or fax to (828) 333-6465.
Up to 10 files may be uploaded.

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1 Referring Source

2 Patient Information

3 Insurance Information

4 Contact Information

5 Referral Details

6 Additional Referral Details

7 Patient Documents