MediTelecare Resident Referral Form

Facility Information

Patient Information

Physician Order

Please fax all patient face sheet documentation to (877) 794-3529.

Consent and Authorization to Screen, Evaluate and Treat

MediTelecare™ offers behavioral healthcare services. Our behavioral health team partners with primary care physicians, families and patients to diagnose and improve psychiatric symptoms such as depression, anxiety and memory problems and address overall behavioral health and wellness.

By affixing my signature below, I consent to and authorize the MediTelecare™ team to screen me/my loved ones, review their medical chart, and when medically necessary evaluate and treat by providing services that may include diagnostic screening, clinical interview, psychotherapy, group counseling, medication management, cognitive assessment and care planning, psychological testing, and Behavioral Health Integration Services (BHI) and/or Chronic Care Management Services (CCM) as outlined in the "Notice To Patients Regarding Consent to Screen, Evaluate and Treat." Additionally, I am aware that I may revoke this consent at any time as long as I do so in writing.

By signing my name below, I agree to MediTelecare's™ "Telemedicine HIPAA Notice of Privacy Practices" and "Notice To Patients Regarding Consent to Screen, Evaluate and Treat" policies.