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PHP/IOP/SOAP Referral Information Request for Services Referral to: Bridge pH: 7814776938 F: 7814776949 Beverly pH: 9788162812 F: 9785246072 Discover pH: 9782834000 X422 F: 9784916573 Referrer Name:
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This form is used to provide referral information for patients seeking health services at NEB Health.
Healthcare providers and facilities referring patients to NEB Health are required to file this form.
The form must be filled out with detailed information about the patient being referred, the referring healthcare provider or facility, and the reason for the referral.
The purpose of this form is to streamline the referral process and ensure that all necessary information is provided to NEB Health for the continuity of care.
Information such as patient demographics, medical history, reason for referral, referring healthcare provider details, and any relevant medical records must be reported on this form.
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