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Transitional Living Services of Northern New York 482 Black River Parkway Watertown, New York 13601 (315) 7821777 (315) 7858628 REFERRAL TO ADULT JEFFERSON COUNTY PROGRAMS Date: Referring Agent: Title:

How to fill out adult referral

How to fill out an adult referral:

1. Start by obtaining the necessary referral forms from the appropriate source, such as a doctor's office, hospital, or healthcare provider.
2. Carefully read through the instructions provided with the referral form to ensure you understand the requirements and the information that needs to be provided.
3. Begin filling out the referral form by providing your personal information, such as your full name, date of birth, address, and contact information. Make sure to accurately and legibly fill in these details.
4. Move on to the section that asks for your medical history. Provide information about any existing medical conditions, allergies, medications you are currently taking, and any relevant past surgeries or procedures you have undergone.
5. If you have a primary care physician or healthcare provider, include their contact information in the designated section of the referral form.
6. The referral form may ask you to provide details about the healthcare specialist or facility you are seeking a referral to. Ensure you have the necessary information, such as the specialist's name, address, and contact details before proceeding.
7. In the case where there is a specific reason for the referral, provide a clear and concise explanation of why you are seeking specialized care or a second opinion.
8. Now, review the completed referral form to ensure that all the necessary sections have been filled out accurately and completely.
9. If required, make a copy of the referral form for your records before submitting it.
10. Follow any additional instructions given on the referral form regarding where and when to submit it. It could be directly to the specialist or healthcare provider or through your primary care physician or hospital.
11. Keep a record of the submission date and any other details concerning the referral for future reference.

Who needs an adult referral:

1. Individuals who require specialized medical care beyond the scope of their primary care physician.
2. Patients who may need a second opinion on their existing medical condition or treatment plan.
3. Those seeking access to specific healthcare specialists or facilities that require a referral for initial consultation or treatment.

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What is adult referral?

Adult referral is a process of referring an adult for services or support to address their needs.

Who is required to file adult referral?

Any individual or organization who has knowledge of an adult in need of services or support can file an adult referral.

How to fill out adult referral?

To fill out an adult referral, one must provide relevant information about the adult in need, their situation, and the services required.

What is the purpose of adult referral?

The purpose of adult referral is to connect adults in need with appropriate services or support to address their specific needs.

What information must be reported on adult referral?

Information such as the adult's name, contact information, needs, and any relevant background information must be reported on an adult referral.