Make A PDF Referral | Health Connect America

Health Connect America provides the option to download a referral form for those who cannot submit an online referral. Simply select a office to get get started. Fill out the field in the form below to generate a PDF based on the information you entered. Make sure you choose the Download PDF button at the bottom of the page.

If you are looking for Online Referrals, click on the button below.

Your PDF will print with contact information. You can print a blank PDF for a particular office by first choosing an office and then click on Download Blank PDF button. or you can fill out the fields below to create a completed PDF referral form.

Referring Agency Contact Information

Have you informed the person/family that you are referring them for services?

Client Information

Select a State

Select a Gender

Select a Race

Select a Ethnicity

Select a Legal Status

Tobacco Use

Smoking Status

If client is underage or Adjudicated Incompetent as Adults:

Additional Questions

Insurance Information

Is there a secondary insurance?

Has a letter of service denial been received from second insurance?

Phone :

Make A PDF Referral