PRP Adult Referral Form

Prolific Health Programs

PRP Adult Referral Form

These forms are used to make a referral to PHP Psychiatric Rehabilitation Program(PRP). Please, Fax completed form to 410-878-7119.

Download PRP Referral form as ( PDF) here.

You can also complete the form below to make a referral.

PRP-Adult

Step 1 of 5

20%

PRP Adult

Date(Required)

Month

Day

Year

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Social Security #

Birth of Date(Required)

Month

Day

Year

Age(Required)

Medicaid # (if known)

Marital status(Required)

Single

Divorced

Widowed

Significant other

Employed(Required)

Yes

Has this individual received PRP services before?(Required)

Yes

Program Name:

Dates of service (if known)

Month

Day

Year

PRP Adult

Current Diagnosis(Required)

296.31 Major depressive disorder, Recurrent episode, Mild

296.32 Major depressive disorder, Recurrent episode, Moderate

296.33 Major depressive disorder, Recurrent episode, Severe

296.51 Bipolar I disorder, Current or most recent episode depressed, Mild

296.52 Bipolar I disorder, Current or most recent episode depressed, Moderate

296.53 Bipolar I disorder, Current or most recent episode depressed, Severe

296.41 Bipolar I disorder, Current or most recent episode manic, Mild

296.42 Bipolar I disorder, Current or most recent episode manic, Moderate

296.43 Bipolar I disorder, Current or most recent episode manic, Severe

295.90 Schizophrenia

295.70 Schizoaffective disorder, Bipolar type

295.70 Schizoaffective disorder, Depressive type

PRP Adult

Has this individual been impaired for at least 2 years in any of the following categories? Please check at least 3 of the following categories if applicable(Required)

Marked inability to establish or maintain independent competitive employment: characterized by an established pattern of unemployment, underemployment, or sporadic employment that is primarily attributable to a diagnosed Page 16 of 47 BH2564_01/2020 serious mental illness, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems.

Marked inability to perform instrumental activities of daily living (shopping, meal preparation, laundry, basic housekeeping, medication management, transportation, and money management) that is primarily attributable to a diagnosed serious mental illness, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems.

Marked inability to establish or maintain a personal support system, characterized by social withdrawal or isolation, interpersonal conflict, or social behavior (other than criminal behavior) that is not easily tolerated in the community and primarily attributable to a diagnosed serious mental illness, and which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems

Marked or frequent deficiencies of concentration, persistence or pace that is primarily attributable to a serious mental illness resulting in a failure to complete in a timely manner tasks commonly found in work, school, or home settings, which requires intervention by the behavioral health system beyond what is available to the individual from by mainstream workforce development, educational, faith-based, community or social service organizations

Marked inability to perform or maintain self-care (hygiene, grooming, nutrition, medical care, personal safety) that is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations

Proper interaction with peers

Marked deficiencies in self-direction, characterized by an inability to independently plan, initiate, organize, and carry out goal-directed activities that is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations.

Marked inability to procure financial assistance to support community living, which inability is primarily attributable to a serious mental illness, and which requires intervention by the behavioral health system beyond what can be reasonably provided by mainstream workforce development, educational, faith-based, community or social service organizations. This does not include limitations due to factors such as geographic location, poverty, lack of education, availability of transportation, or loss of driver’s license due to legal problems.

PRP Adult

Consent(Required)

I understand that I am making a referral for PRP services and said services must be authorized by Optum Md before any PRP services may begin.

Referred By (Name & credentials)(Required)

Date(Required)

Month

Day

Year

Name of Facility or Program(Required)

Program /Facility Address

Program /Facility Phone(Required)

Program /Facility Email

PRP Adult

Referral Authorizations(Required)

I agree to the referral authorization terms

Referral Authorizations

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Prolific Health Programs. I authorize payment of medical benefits to Prolific Health Programs. I also understand that payment of is my responsibility and Prolific Health Programs has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Prolific Health Programs. I authorize payment of medical benefits to Prolific Health Programs. I also understand that payment of is my responsibility and Prolific Health Programs has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Prolific Health Programs. I authorize payment of medical benefits to Prolific Health Programs. I also understand that payment of is my responsibility and Prolific Health Programs has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

Typing my name below serves as my digital signature.

Digital Signature(Required)

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*Prolific Health Programs Accepts
Active Medical Assistance & Medicare.

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Here at PHP we are a family oriented, recovery driven organization. We are firm believers that it takes a village to foster a cultivate caring environment to make a difference. Your support will mean the world to us. Weather you choose to donate your time, talent, or treasure, your contribution directly impacts the lives of our participants, their families, and our staff . Your generosity will make a huge impact to our family.

We will appreciate monetary donations, gift cards, Educational & Recreational tickets to local museums & concerts, Bus passes, Used or new clothing & shoes, Non- perishable food items, house hold supplies, shopping, restaurants ,Just to name a few. Again, any small or large donation will make a significant difference to our participants. We thankyou so much !

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