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.

I agree to receive follow-up messages by email.*

I agree to receive follow-up messages by text (SMS).**

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, Texas, and Washington.

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.

*Messaging frequency varies. I can unsubscribe at any time.

**Messaging frequency varies. Message and data rates may apply. I can opt out at any time by replying STOP. I can reply HELP to receive support. If I do not consent to receive SMS, and Workit Health is unable to reach me by email, I understand that they will not be able to contact me by text.

View our Privacy Policy, Terms of Service, and Consent to SMS and Email.

SMS Agree

Input Patient Info Below