Dose Health Referral Form                            
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Billing Information
NPI# 1891155909
FAX: 844.525.0515
Your Information
Please fill out your information, so we know who is submitting this referral
I am a *
Your First Name *
Your Last Name *
Your Email Address *
Services
For a description of our different services please click here: https://www.dosehealth.com/services
Choose the services requested: *PERS and PERS+ are only covered by HCBS Medicaid Waivers in Minnesota and Oregon* *
Required
Adaptive Equipment
Special Request Adaptive Equipement
Client Information
Please provide information for the person who will be receiving the service(s)
Client First Name *
Client Last Name *
Date of Birth *
PMI / Member / Subscriber Id #
Client Phone
Address Line 1 *
Street address, P.O. box, company name, c/o
Address Line 2
Apartment, suite, unit, building, floor, etc.
City *
State *
Zip Code *
Waiver Case Manager | Waiver Care Coordinator Information
Please provide contact information for the person who will approve services if requesting through the Medicaid Waivers
Care Manager First Name
Care Manager Last Name
Care Manager Phone
Care Manager Email
Family Member | Caregiver
We will contact this person to setup services and discuss the individual's needs
Who should we contact to setup services? *
Are they aware this service is being requested?
Clear selection
Family Member | Caregiver First Name
Family Member | Caregiver Last Name
Family Member | Caregiver Phone
Organization (if applicable)
Notes
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