Referral form

Referral for Bridge Health IDD Program
Individuals Information
Name*

First NameLast Name
Address*

Address

Indirizzo Riga 2

CityState

Post Code
Phone Number*
Social Security Number*
Date of Birth*

MonthDayYear
Date
Living Situation

AloneWith Parent(s)SpouseChildrenFriendsOther
Service Information
Services requested: (select all that apply)*

Community Access IndividualDay ProgramFamily SupportsResidential ServicesSpecialized Medical SuppliesNursing ServicesSupported EmploymentOther
Waiver Information
Does the individual being referred currently have an active Medicaid Waiver?*

YesNoOther
Which Medicaid Waiver is the individual currently under?

COMPNOW
To better assist in the determination of services for the individual please visit this link to apply for a Medicaid Waiver upon completion of the referral form.

https://medicaid.georgia.gov/programs/all-programs/waiver-programs
Primary Insurance Information
Insurance Information

MedicaidMedicareAmerigroupCareSourcePeachStateWellCarePrivate Insurance
Insured Identification Number
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the individual have a secondary insurance?

YesNo
Secondary Insurance Information

Skip section if not applicable
Insurance Information

MedicaidMedicareAmerigroupCareSourcePeachStateWellCarePrivate Insurance
Insured Identification Number
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Diagnosis Information
Primary Diagnosis*
Secondary Diagnosis
Other Medical Diagnoses
Referring Agency Information
Agency Name*
Referral Staff Name*

First NameLast Name
Referring Agency Admission Date (date individual came to your agency)

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
E-mail
Medical/Psychiatric Information
Medications*
(Name, Dose, Frequency)
History of Medication Compliance

ExcellentGoodFairPoor
How does individual behave when off medications?
Currently uses alcohol/drugs?

YesNo
If Yes, please explain
Compliance with treatment plan

ExcellentGoodFairPoor
Comments
Psychiatric Hospitalizations
(Hospital Name, Date, Length of Stay)
Psychosocial Treatment Needs
Behavioral Concerns/Comments*
List all services provided to this individual during the past twelve months
Interpretive Summary (last 90 days)
Living Skills

Rate living skills in the following areas

	Doesn't Need Assistance	Needs Some Assistance	Needs Ongoing Assistance
Housekeeping
Food Prep/Storage
Grocery Shopping
Transportation
Communication (use phone, make appointments)
Leisure time planning
Money Management
Ability to Arrange Healthcare
Interpersonal Skills

Other Information
Please click 'Browse' to select and upload any supporting documentation
Should be Empty:

Referral for Bridge Health IDD Program

Individuals Information

Service Information

Waiver Information

Primary Insurance Information

Secondary Insurance Information

Diagnosis Information

Referring Agency Information

Medical/Psychiatric Information

Living Skills