Calvert County Health Department PROVIDER Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form for your patients who would benefit from one or more of our services. No medical referral required.

Email *

Is this a self referral?

Yes

Clear selection

Name of patient *

Patient Date of Birth *

YYYY

Date of referral *

YYYY

Patient phone number and email *

What is the patient's preferred options for outreach from the CCHD?

Phone call

Text message

Referring provider name *

The patient verbally consents to the following: "I agree to share the health information listed on this form with Calvert County Health Department for follow up". *

Yes

Required

Which program are you referring your patient to? *

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, x355

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, x514

Tobacco Cessation program - a FREE 8 week course, including free medications for tobacco cessation. 410-535-5400, x359

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, x343

Destination Wellness - a FREE outpatient care navigation 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, x459

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, x400 or 405

Health Insurance

Medical Assistance Transportation

Required

Is a Spanish Interpreter needed for your referral?

Yes

Clear selection

For diabetics, please enter most recent A1c and date of test.

For pre-diabetics, please enter most recent A1c and date of test.

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.

If referring to Destination Wellness, 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

Clear selection

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of State of Maryland.

Does this form look suspicious? Report

Forms