Get H2rcc

Filling out the H2rcc form online is a straightforward process that allows users to efficiently submit a new patient referral to the Referred Care Clinic. This guide will walk you through each section of the form, ensuring that you provide all necessary information accurately.

Follow the steps to complete the H2rcc form online.

1. Click the ‘Get Form’ button to access and open the H2rcc form in the online editor.
2. In the 'Referred By' section, enter the name of the individual or organization making the referral.
3. Fill in the 'Date of Referral' using the YYYY/MM/DD format to indicate the day the referral is being made.
4. In the 'Patient Name' field, provide the full name of the person being referred.
5. Enter the YHCIP number, if applicable, in the designated box.
6. Record the 'Date of Birth' of the patient in the YYYY/MM/DD format.
7. Indicate the patient's gender by selecting either 'Male' or 'Female.'
8. Provide the patient's address, including any relevant postal code information.
9. Enter the patient's telephone number for contact purposes.
10. In the 'Contact Person' section, fill in the name and telephone number of someone who can be reached for further information.
11. If applicable, include the name and telephone number of the patient's previous medical doctor or clinic.
12. Provide information about any counselors or other programs the patient has been involved with, including their contact numbers.
13. If there are any additional contact persons, list their names and telephone numbers.
14. Clearly state the 'Reason for Referral,' detailing the specific concerns or needs of the patient.
15. Outline any relevant previous counseling or mental health history and treatment that the patient has received.
16. Detail any substance use history and prior treatments if applicable.
17. List any current medications the patient is taking, along with dosages where necessary.
18. Include any medical concerns or other important information that may be relevant to treatment.
19. Review the completed form for accuracy and completeness.
20. Once satisfied with the information provided, save the changes. You may also download, print, or share the completed form as needed.

Complete your H2rcc form online today for efficient submission.