Make A Referral

Clinical/Case Management
Submit your Clinical/Pharmacy/Case Management referral by using our online form.

You may also submit a referral by fax or email by completing the Clinical Services PDF form.


Medicare Compliance
Submit your Medicare Compliance referral by using the client web portal

You may also submit a referral by fax or email by completing the Medicare Compliance Services PDF form.

Releases and Proof of Representation
We have also provided releases and forms to help complete the referral process.

HIPAA Release   (HIPAA formulario en español)
SSA Release
Beneficiary Proof of Representation Form
Insurer Proof of Representation Form
Letter of Authority Template

Releases and proof of representation forms can be emailed or faxed to:



Section 111 Forms

SSN Model Language Form