CHARITABLE HEALTH CARE PROVIDER PROGRAM

* Patient/Guardian Signature:

* Date:

* If treatment for a minor child, indicate relationship to child:

For Referring Clinic Use:

* Referring Free Clinic Name:

* Name of Referring Provider:

* Patient's Information:

* Patient Information:

Date of Birth:
/
/

* Reason for referral:

* Referring Provider Signature or Designee:

* Date:

As needed, the above-named health care provider is intending to refer this patient to a charitable health care provider who is under contract as provided at 51 O.S. Supplement 2007, Section 152.2.

As needed, the above-named health care provider is intending to refer this patient to a charitable health care provider who is under contract as provided at 51 O.S. Supplement 2007, Section 152.2.

* Information for Specialist Receiving Referral:

* Apointment Date and Time:

Date:
/
/
:

* Response to Referring Provider
(actual services provided by specialist)

* Date(s) of Services Rendered:

* Estimated Value of Health Care Provided:

* (Receiving) Volunteer Specialist Provider

* Date:

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