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Provider Referral Form

(HIPAA compliant form)

Referring Source Details

Name of Referring Individual

Referring Source Phone

Referring Source Email

Facility Details

Patient's Contact Details

Gender (assigned at birth)

Birthday
Month
Day
Year

Reason for Referral

Insurance information (if known/optional)

Additional Documents

(copies of insurance card, health records, discharge summary, etc.)

Provide cloud link below or Email separately

Confidentiality and Privacy Assurance

At Copacetica Health, we prioritize your privacy and the confidentiality of your personal information above all else.

We understand the sensitivity of the information you provide and are dedicated to protecting it with the highest level of care and security.

All data collected is safeguarded under stringent confidentiality protocols and is accessible only to authorized personnel who require it to deliver our exceptional services.

We comply with all relevant privacy laws and regulations to ensure your information remains secure. Any data you share will be used solely for the purpose of providing you with the highest quality of care and service. We are committed to transparency and will keep you informed about how your data is being used.

Your trust is of utmost importance to us, and we continuously work to uphold and strengthen that trust by implementing robust data protection measures. If you have any concerns or questions about our privacy practices, please do not hesitate to contact us.


Thank you for entrusting Copacetica Health with your care.

mental health matters
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