Follow the steps to complete the referral form easily.

1. Click ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by entering the date of the referral in the specified format. Ensure that the date is current and clearly presented.
3. Include all required documents with your referral, such as any previous psychological, psychosocial, or medical documentation, a copy of insurance card(s), and an Individualized Service Plan (ISP).
4. Indicate whether transportation is medically necessary for the individual. Select 'Yes' or 'No' based on the individual's needs.
5. Specify if the individual uses a wheelchair by selecting 'Yes' or 'No'. Additionally, indicate if someone will accompany the individual using the same options.
6. Fill in the individual’s personal details including first name, last name, date of birth, sex, address, city, state, zip, and type of residence (family, ICF, IRA, CR, or other).
7. Complete the contact information fields, including home phone, cell phone, parent's or guardian's name, and emergency contact details.
8. Provide the individual's Social Security number, Medicare number, Medicaid number, or select 'No Insurance' as applicable.
9. List the primary diagnosis and indicate the primary language spoken by the individual.
10. Identify the day service provider or employer and indicate if this is a day treatment program. Include the program director’s details.
11. If the individual attends other Article 16 clinics, provide details about those providers, including their name, type of clinic, and contact information.
12. Document current medications, dosages, and any known allergies or special alerts that are pertinent.
13. Check all services requested from the list provided, ensuring that the selections accurately reflect the individual's needs.
14. Describe the reason for the referral, including the presenting problem, and provide the source of referral details.
15. Confirm that both the primary caregiver and individual agree with the referral, as well as the service coordinator’s agreement. Attach explanations if there is any disagreement.
16. Upon completion, save changes to the form and ensure it is properly downloaded or printed for submission.
17. Fax the completed referral to (718) 855-7717 or mail it to HeartShare Clinic, 177 Livingston Street, Brooklyn, NY 11201.

Take the next step in securing necessary services by completing your Article 16 Referral Form online today.