Referral

Make a referral to Unique NC Health Services

Complete the form below to submit a referral for services. Our team will review the information provided and follow up regarding next steps.

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Person making the referral *

First

Last

Referring Agency/Organization

Referrer Email *

Referrer Phone Number *

Person being referred *

First

Last

Date of birth *

Person's Phone Number

Acknowledgment Health Name

Service(s) Requested *

• Community Living and Supports
• Respite

County of Residence *

Health Plan/LME-MCO (if known) *— Select Choice —Partners Health ManagementVaya HealthHealthy BlueUnsure

Care Manager/Care Coordinator Name

Care Manager/Care Coordinator Email

Care Manager/Care Coordinator Phone Number

Reason for Referral/Additional Information *

Preferred Method of Contact *

• Phone
• Email
• Either

Referral Authorization and Privacy Acknowledgment *

• I confirm that I am authorized to submit this referral and provide the information included in this form.

Submit