Get Canada Portico Network Referral Fax Cover Page

Completing the Canada Portico Network Referral Fax Cover Page is an essential step for users seeking to refer clients for mental health services through telemedicine. This guide provides step-by-step instructions to assist you in accurately filling out the form online.

Follow the steps to complete the referral fax cover page successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Fill in the 'Date of Referral' section with the current date of your referral. Use the format MM/DD/YYYY for clarity.
3. In the 'Referring Site' field, input the name of the clinic or organization making the referral.
4. Enter the 'Primary Care Provider Name'. This should be the name of the healthcare professional referring the client.
5. Fill in the 'Phone Number' field with a reliable contact number for the primary care provider.
6. Provide the 'E-Mail' address for the primary care provider to ensure they can be contacted easily.
7. If known, specify the 'Client Preferred OTN Site' to help facilitate scheduling.
8. Input the 'OTN Site Name' related to the referral.
9. Include the 'OTN System Number' to ensure appropriate identification within the system.
10. Record the 'OTN Site Coordinator' name and their direct contact 'Phone Number' for booking the OTN appointment.
11. Provide a 'Phone Number' that can be reached during the OTN appointment for immediate contact.
12. Fill in the 'E-Mail' section for the OTN site, ensuring communication lines remain open.
13. Document the 'Client & OTN Site Weekly Availability' by selecting the days and noting available times from 9 am to 8 pm EST. Repeat for the client and the OTN site as applicable.
14. After completing all required fields, review the information for accuracy and completeness.
15. Save the changes made to the document, then choose to download, print, or share the form as needed.

Complete your Canada Portico Network Referral Fax Cover Page online today to ensure a smooth referral process.