MediTelecare Resident Referral Form

By securely sending us referral information through our HIPAA compliant form you are adhering to PHI guidelines.

Please fill out the fields below to let us know who is submitting this resident referral.
- Referral submitter first name*
- Referral submitter last name*
- Your Title*
- Referral submitter's email address*
- Referral submitter's phone number*
- Facility Name*
- Hidden
  Facility Name Confirmation
Enter patient to be referred:*
First Last
Patient Date of Birth:*
MM slash DD slash YYYY
Please select a reason for referral (check all that apply):
- Psycho-Medication Monitoring
- Depressive Symptoms
- Anxiety
- Memory Problems/Confusion
- Poor Oral Intake
- Change in Sleep Pattern
- Mental Status Change
- Verbal Abuse
- Physical Abuse
- Inappropriate Behaviors
- Thought Disorder
- Adjustment Difficulty
- Substance Abuse/ Alcohol or other substances
- Elopement Risk
- Non Compliance with Medical Treatment
- Other
If other:*
Hidden
Enter patient(s) to be referred: (click + button to add more rows for more patients)
Patients Name (first and last) Date of Birth

(click + button to add more rows for more patients)
Physician's Order & Face Sheet
Please choose a selection below that best describes the physician order & face sheet:*
- I authorize MediTelecare to retrieve the face sheet and physician order from facility EHR
- I’ve obtained a physician order and a face sheet and will fax documents
- I will upload a completed physician order and face sheet
- I want to fill out a new physician order, and upload a face sheet
Physician Order Attestation Statement*
By checking this box, I attest that I have obtained a physicians order for MediTelecare to evaluate and treat psychiatric and psychological health for the patient named in this referral form, and will fax all documentation to (877) 794-3529.
- Click the Choose File button to select your Physician Order file to upload*
  Drop files here or
  
  Max. file size: 5 MB.
- Click the Choose File button to select your Face Sheet file to upload
  Drop files here or
  
  Max. file size: 5 MB.
Physician Order Details

Physician Order for Services Should Be Written:
"Meditelecare to Evaluate and Treat for Psychiatric and Psychological Health"
Order Date*
MM slash DD slash YYYY
Communication Method:*
- Phone
- Verbal
- Prescriber written
- Prescriber entered
Ordered by (Physician name):*
First Last
NPI number of ordering Physician
Description of order:*
MediTelecare to Evaluate and Treat for Psychiatric and Psychological Health.
- Optional File Upload for Medical History, List of Medications or Other Documentation
  Drop files here or
  
  Max. file size: 5 MB.
- You can drag and drop your Face Sheet into the box below or click the button to select your file.*
  Drop files here or
  
  Max. file size: 5 MB.
Consent and Authorization to Screen, Evaluate and Treat
Please choose a selection that best describes the consent you have received from the patient*
- I wish to fill out a new Consent and Authorization to Screen, Evaluate and Treat form for this patient
- I have obtained a signed Consent and Authorization to Screen, Evaluate and Treat for this patient and will fax the form to MediTelecare
- I have obtained a signed Consent and Authorization to Screen, Evaluate and Treat for this patient and will upload the form to MediTelecare
Click the choose file button to select your Consent and Authorization to Screen, Evaluate and Treat file to upload*
Drop files here or

Max. file size: 5 MB.
Consent and Authorization to Screen, Evaluate and Treat Attestation Statement*
By checking this box, I attest that I have obtained a a signed Consent and Authorization to Screen, Evaluate and Treat form for the patient named in this referral form, and will fax it to (877) 794-3529.
Consent and Authorization to Screen, Evaluate and Treat

MediTelecare™ offers behavioral healthcare services via telehealth. Our neuropsychiatric team partners with the primary care physicians, families and patients to diagnose and improve neuropsychiatric symptoms such as depression, anxiety and memory problems.

By affixing my signature below, I consent to and authorize the MediTelecare™ team to screen me/my loved ones, medical chart. I understand that if the screen suggests that the undersigned will benefit from mental health services, and if the primary care provider is in agreement, I consent to and authorize an evaluation and treatment by MediTelecare™ including 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," "Notice To Patients Regarding Consent to Screen, Evaluate and Treat," and "License Agreement" Policies.
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Facility Name:*
Name of Signatory*
First Last
Today's Date*
MM slash DD slash YYYY
Email Address of Signatory*
Consent obtained from:*
- Patient
- Staff member
- Other (family member/legal guardian/power of attorney)
Name of person consent was obtained from:*
First Last
Date consent was obtained*
MM slash DD slash YYYY
Relationship to patient:*
- Healthcare Representative/Power of Attorney
- Spouse
- Sibling
- Executor/Administrator of Estate
- Other Authorized Legal Representative
Please check the attestation below*
- I am an authorized agent of this facility and am permitted to refer patients to MediTelecare
Initials of individual checking the attestation*
Please read and accept MediTelecare's Privacy Policy below then sign your name in the grey box and click the red "Submit" button to securely send your form.

If you are experiencing technical difficulties, please use the methods below to submit referral forms:

Email: intake@meditelecare.com
Fax: (877) 794-3529

Chat with usLiveChat

Patients Name (first and last)	Date of Birth

MediTelecare Resident Referral Form

By securely sending us referral information through our HIPAA compliant form you are adhering to PHI guidelines.

Physician's Order & Face Sheet

Physician Order Details

Consent and Authorization to Screen, Evaluate and Treat

Consent and Authorization to Screen, Evaluate and Treat

Please read and accept MediTelecare's Privacy Policy below then sign your name in the grey box and click the red "Submit" button to securely send your form.