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Calvert County Health Department PROVIDER Referral Form
Please complete this form for your patients who would benefit from one or more of our services. No medical referral required.
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* Indicates required question
Email
*
Your email
Name of patient and their DOB
*
Your answer
Date of referral
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MM
/
DD
/
YYYY
Patient phone number and email
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Your answer
What is the patient's preferred options for outreach from the CCHD?
Email
Phone call
Text message
Referring provider name
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Your answer
The patient verbally consents to the following: "I agree to share the health information listed on this form with the Calvert County Health Department for follow up".
*
Yes
No
Required
Which program are you referring your patient to?
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Living Well with Diabetes - a FREE 6 week workshop providing self-management tools for adults with type 2 diabetes and pre-diabetes. 410-535-5400, ext 355.
Diabetes Prevention Program - a Free year long lifestyle change program which helps you learn ways to improve your overall health and reduce weight. 410-535-5400, ext. 514.
Tobacco Cessation program - a FREE 8 week course, including free medications for tobacco cessation. 410-535-5400, ext 359.
Colorectal, Breast, Cervical, and Lung Cancer Screening - Screening AND DIAGNOSTIC testing for eligible community members, including those with Medicare, Private insurance, no insurance and Medical Assistance. 410-535-5400, 343.
Highway to Health - a FREE outpatient case management system for the community - 443-624-2586.
Healthy Hearts Blood Pressure Self-Management Program - a FREE 4 month lifestyle change program for those adults with hypertension - 410-535-5400, ext.459.
Maternal Child Health - Free Case Management for pregnant or postpartum (up to a year) women that have a history of substance use disorder, homeless status, and/or severe mental health - 410-535-5400, ext 400 or ext 405.
Required
Is a Spanish Interpreter needed for your referral?
Yes
No
Clear selection
For diabetics, please enter most recent A1c and date of test.
Your answer
For pre-diabetics, please enter most recent A1c and date of test.
Your answer
For smokers, please clarify what type of product to which the patient is addicted.
Cigarettes
E-cigarettes/Vapes
Cigars
Dip/Chew
Clear selection
For those with hypertension, please enter most recent BP measurement and date of check.
Your answer
If referring to Highway to Health, please list area(s) of need.
Needs PCP
Needs Assistance with Insurance
Health Education Program Assistance
Assistance with Medical Appointments
Other:
Is this an internal CCHD referral?
Yes
No
Clear selection
A copy of your responses will be emailed to the address you provided.
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