OMHC Referral Form

Prolific Health Programs

OMHC Referral Form

These forms are used to make a referral to PHP Outpatient Mental Health Clinic (OMHC) Program. Please, Fax completed form to 410-878-7119.

Download OMHC Referral form as ( PDF) here.

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

Outpatient Mental Health Clinic

Step 1 of 3

33%

Referral Source

Referring Provider Name

Agency

Contact Phone #

PATIENT DEMOGRAPHIC INFORMATION

Parent/ Guardian Name

Relationship

Phone Number

Email Address:

*A LEGAL DOCUMENT MUST BE PRESENTED TO SHOW GUARDIANSHIP *

Patient’s Name:

Address

Street Address Address Line 2 City State ZIP Code

Home Phone #

Mobile Phone #

Social Security #

Date of Birth

Month

Day

Year

Gender

Male

Female

Race

Marital Status

Single

Married

Widowed

Divorced

Insurance Type

Medicare

Other

Medical Assistance #

Emergency Contact Name

Relationship to Patient

Contact #

Primary Care Physician

Clinic Name

Phone

Current Type of Housing (e.g., group home)

Veteran

Yes

Potential Transportation Issues?

Yes

Explain (transportation issue)

CLINICAL INFORMATION

Reason for Referral

Diagnosis (list confirmed if known, if not list suspected

Primary Psychiatric Diagnosis

Secondary Psychiatric Diagnoses (including substance abuse)

Relevant Medical Diagnoses

Relevant Social Factors

Past Psychiatric History (hx) and Treatment (please check appropriately)

Former patient in clinic referred to?

Yes

Explain

Hx of violence?

Yes

Explain

Hx of suicide attempts?

Yes

Explain

Hx of psychiatric hospitalizations?

Yes

Explain

Previous symptoms and diagnoses

Current Psychiatric Treatment & History

Current Symptoms

Current suicidal / homicidal thoughts?

Yes

Explain

Does patient have a current outpatient mental health provider?

Yes

Explain

Reason not returning

Additional Information

Current Psychiatric Medications (name & dose, attach list if preferred)

Consent(Required)

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

Date

Month

Day

Year

Time

Hours

Minutes

AM/PM

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)

Your recovery journey starts here and starts NOW

*Prolific Health Programs Accepts
Active Medical Assistance & Medicare.

Social Media

Links

Careers
Services
Resources
Donate

Donate

Donations

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 !

Click Here To Donate