Get Integra Referral Form 2013-2026

The Integra Referral Form is an essential document for facilitating referrals to necessary services. This guide provides step-by-step instructions to help you complete the form online with confidence and ease.

Follow the steps to accurately complete the form.

1. Press the ‘Get Form’ button to access the Integra Referral Form and open it in your chosen editor.
2. Fill in today's date at the top of the form. This information is crucial for tracking the referral timeline.
3. Indicate your relationship to the individual being referred by selecting the appropriate option (provider, family/caregiver, other) and providing relevant details if necessary.
4. Complete the section regarding whether you have discussed the referral with the client by selecting 'Yes' or 'No'. This indicates the level of communication between you and the client.
5. In the 'Information about Individual Being Referred' section, fill out the individual's name, age or date of birth, phone number, gender, and living situation ('Yes' or 'No'). Accurate information helps provide tailored support.
6. Provide the individual's address, borough of residence, Medicaid number, other health insurance details, and Medicare number, if applicable. This data is essential for insurance processing.
7. If there are any special communication needs or preferred language, specify them in the corresponding fields.
8. List any known medical issues, including diagnosis or conditions and medications, in the appropriate section. This information is vital for understanding the individual's needs.
9. For the mental status, select from the provided options (alert, confused, anxious, memory issues, other) to describe the individual’s mental health. This supports tailored outreach.
10. Detail functional status and types of assistance needed, marking all relevant activities of daily living (ADL) and instrumental activities of daily living (IADL) where assistance is required.
11. Finally, review all completed sections for accuracy. Users can then save changes, download, print, or share the completed referral form to finalize the submission.

Start filling out the Integra Referral Form online today to ensure timely support.