Referrals – Access Behavioral Health Center

Patient Referrals

Follow these steps:

1. Retrieve the Patient Referral Form.
2. Please filled in the patient’s required details for referral.
3. Send the filled-out form via fax to any of our ABHC locations listed on the form or available here.

4. Complete the online referral form below, and we’ll take care of the rest—no printing or faxing needed!

Patient Referrals Form

Date

MM slash DD slash YYYY
Please confirm today’s date:Please provide your details for the referral:Referred by:(Required) Please fax this referral to:Diagnosis/Reason for referral:

Select which apply:

Mental Health

Second Choice

We will call the client, schedule an appointment, and fax information back to you. (Please provide the information below)Telephone Number:(Required)Fax Number:Email(Required)

Insurance Type(Required)

Medicaid and MyCare-Ohio

Commercial

Medicaid and MyCare-Ohio

Aetna Better Health Of Ohio

Buckeye Health Plan

Molina

United Health Care (Community Plan)

CareSource

Anthem Blue Cross and Blue Shield

ID# MMIS# GROUP#

PMI # MEDICAL ID # GROUP #

Please share your patient details for the referral:Full Name: Male/Female:Parent/Guardian Name: Relationship to Patient: Street Address: City: County: State: Zip: Home Phone Number:Cell Phone Number:Work Number:Emergency Contact Telephone Number:Marital Status: Date of Birth:

MM slash DD slash YYYY
Age:CAPTCHA