HRSA Referral Form

Referrer's Relationship to Patient*

"Other"—What is your relationship to the patient?

Referring Person's First Name*

Referring Person's Last Name*

Provider Name*

PrefixFirst NameLast Name

What is your Organization/Practice Name?

Organization Location

Email*

example@example.com

Phone Number

Please enter a valid phone number.

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Individual's First Name*

Individual's Last Name*

Insurance Type/Payment Method (if known)

Insurance Carrier (if known)

Individual's Phone*

Please enter a valid phone number.

Individual's Email*

example@example.com

City*

County

State*

Requested Workit Services (select all that apply)*

Opioid UseAlcohol Use

Upload a completed Release of Information form (Note: form must be fully legible.)

Workit Health is currently accepting new members and reaching out to referrals in the following states: Arizona, Florida, Illinois, Michigan, Montana, New Jersey, New Mexico, Ohio, Oklahoma, and Texas.

This grant is only available to certain uninsured and under-insured individuals in the following Ohio counties: Ashland, Ashtabula, Crawford, Darke, Erie, Hancock, Hardin, Huron, Logan, Marion, Morrow, Preble, Sandusky, Seneca, Shelby, Wayne, and Wyandot. People with private insurance, Medicare, or Medicaid that fully covers their treatment will not be eligible.

Input Patient Info Below