State of Maryland Local Care Team Referral Form

Instructions

• Please complete the form to make a referral to the Local Care Team.
• Parents/caregivers who are completing the form should provide as much information as possible. The Local Care Team coordinators will assist with completing the form as needed to ensure all relevant information is obtained.
• Forms must be transmitted using appropriate encryption to ensure the confidentiality of protected health information.
• Consents and releases should be obtained as necessary. In addition to completing this referral form, please also submit a Consent to Release form. 
• Access the Local Care Team Directory here

Please click on the Submit button below to send your referral form. Thank you.