Public Health Referral Form

Public Health Referral Form
1. Referring Organization/Provider Information
Select referral type*

Self-referralOrganization/Provider Referral
Organization/Provider Information
Organization/Provider Name*
Organization/Provider Address*
Phone Number*
Fax Number
Please enter a valid phone number.
Email Address*
example@example.com
Is this person aware you are making a referral?*

YesNo
Your relationship to this person:
2.a Patient Information
Full Name*
Date of Birth*

MonthDayYear
Patient birthdate
Is the patient considered a minor?*

YesNo
Gender*

MaleFemaleOther
Language preferred*
Interpreter needed?*

YesNo
Address*
Phone Number*
Area code and phone number
How would you like to be reached?*

CallTextEmail
Email
example@example.com
2b. If a minor, Parent/guardian contact information
Full Name*
Date of Birth*

MonthDayYear
Parent/guardian birthdate
Gender*

MaleFemaleOther
Language preferred*
Interpreter needed?*

YesNo
Address*
Best phone number to be reached*
Area code and phone number
Email Address*
example@example.com
How would you like to be reached?*

CallTextEmail
Email*
example@example.com
3. Referral Details
Reason for Referral: Check all that apply*

Child and Teen Check-UpFirst StepsImmunizationsInfectious DiseaseMantoux TestingPregnancy-In-home nurse visits for pregnancy and ongoing supportRecently delivered/postpartum/new infant (under 8 weeks): In home nurse visits for support during postpartum and beyondRefugee/new arrivalSHIP (Statewide Health Improvement Partnership)-see link belowTuberculosisVaccination Record RequestWomen, infants, and children (WIC)65 and older MNCHOICES assessment/waiver/care coordination. Please call Assessment intake number: 507-304-4444Other (please specify)
Narrative: (please provide information on what you are requesting help with)

0/580
4. Clinical Information (if applicable)
Diagnosis Condition
Current Medications
Medical History
Allergies
Previous Referrals (if any)
If no previous Clinical Information, check here

N/A
5. Attachments
Please attach supporting documents here

pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, gif
Cancelof
If no attachments, check here

I have no documents to attach
6. Electronic Consent

By checking the Consent box below, the organization, patient, or their legal guardian consents to the release of the above information for the purposes of receiving public health services from Blue Earth County Public Health.
Consent*

I confirm I have reviewed the information provided and it is accurate to the best of my knowledge.
Printed Name of Patient/Guardian*
Date*

MonthDayYear
Date of Consent
If you wish to receive an email confirmation of receipt of this form, please enter your email here:
example@example.com
Referrals will be processed upon receipt.

Questions?

Please call Blue Earth County Public Health intake line at 507-304-4117 regarding questions if needed.
Should be Empty: