Charm City Care Connection Client Referral Form
Please enter relevant information in the below box. All responses are confidential and stored in a HIPAA compliant manner. If you would like to fill out a paper form instead, please click here. https://drive.google.com/file/d/0B_ogsNCFaq2_NEFOZENfbnptdTQ/view?usp=sharing

Our walk in hours are Tuesdays (1212 N. Wolfe Street) from 6 - 9 PM and Saturdays (2222 Jefferson Street) from 12-5 PM.

If you have any questions, please email our Program Manager, Nancy Kim at nkim@charmcityclinic.org.

Client Name *
Your answer
Client Phone Number *
Your answer
Referring Organization *
Your answer
Organization Point of Contact Name *
Your answer
Point of Contact Phone Number *
Your answer
Point of Contact Email *
Your answer
Reason For Referral *
(insurance/unpaid medical bills/MCO change/etc.)
Your answer
What day/time did you ask this client to come to the clinic? *
Our walk in hours are Tuesdays from 6 to 9 PM and Saturdays from 12 - 5 PM
Your answer
If client consents, I would like updates on how this client's visit went. *
Submit
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