Referral for Rockland Access Transportation Services
Patient Name
Your answer
Date Of Birth
MM
/
DD
/
YYYY
Gender
Is referred for participation in the Rockland Access Transportation Services to
Facility
For the period of
Intake date
MM
/
DD
/
YYYY
Referring Provider Name
Your answer
Provider License #
Your answer
Referring Facility
Your answer
Provider Contact Information
Your answer
For informational purposes current Health insurance plan:
Provider Signature
Your answer
Date
MM
/
DD
/
YYYY
Consent for Transportation of Minor
By signing below, I acknowledge that I am the parent or legal guardian of
Minor Name
Your answer
and I hereby consent to the transportation of my child to the above referenced behavioral health day program. This transportation program is jointly operated by Refuah Community Health Collaborative and Konit Neg Lakay.
I agree and acknowledge that an adult must accompany my child at all times while being transported. In the event that a parent or legal guardian is unable to accompany my child, I hereby grant permission for anyof the following individuals, all of whom are 18 years or older, to accompany my child during the transportation.
Chaperone Names and Relationships to Minor
Your answer
I understand that I may change or update this list at any time.
Signature of Parent/Legal Guardian (Please type)
Your answer
Date
MM
/
DD
/
YYYY
***
By digitally signing this form you agree to give 24 hour notice of ANY schedule changes by calling 845-425-4623.
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