Get Ccac Referral

The Ccac Referral form is essential for individuals seeking community health services. This guide provides clear, step-by-step instructions to help you complete the online form accurately and efficiently.

Follow the steps to successfully complete the Ccac Referral form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin with the Patient Details and Demographics section. Fill in the Health Card number if applicable, or select the 'No Health Card #' option. Enter the patient’s full name, including surname and given name(s). Provide the home address, city, postal code, and telephone numbers.
3. If the treatment address differs from the home address, complete the Address for Treatment section with the relevant details.
4. In the Date of Birth field, enter the patient's birth date in the DD/MM/YYYY format. Indicate their gender by selecting the appropriate option.
5. Indicate the patient's language preferences by selecting whether they speak/understand English and if an interpreter is required. Specify the primary language if it is not English.
6. Fill in the Primary Alternate Contact Person details and select their relationship to the patient. Repeat for the Secondary Alternate Contact Person. Provide necessary contact numbers.
7. Move to the Health Information section. Enter the details of the Community Health Care Provider, including their surname and given name(s), if applicable. Note any relevant diagnosis for referral, reasons for referral, and allergies, if any.
8. Complete the Referring Organization Information section. Fill in the referring organization's name, contact number, and the details of the individual completing the form, including their title, email address, and date.
9. For the Eligibility for Direct Services, ensure that all required conditions are met and noted if faxing the form, including the number of pages.
10. Review all filled sections for accuracy and completeness, then save your changes. You can choose to download, print, or share the completed form.

Complete your documents online to ensure timely access to essential community services.