Continual Care

Clinic Service Request

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(*) Referral Source

(*) Referral Source Agency

(*) Care Coordinator

(*) Care Coordinator Email

(*) Care Coordinator Phone Number

(*) Reason for Referral - Presenting Problem (must be medically necessary)

Patient Information

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(*) Guardian/Advocate

Legal Guardian

Advocate

(*) Guardian/Advocate Name

(*) Guardian/Advocate Phone Number

HCP Name (if applicable)

HCP Phone Number (if applicable)

Day Service Provider/Employer

Day Services/Employer Contact Person

Day Services/Employer Address

Day Services/Employer Phone Number

Day Services/Employer Schedule

(*) Medicaid ID

Medicare ID (if applicable)

Other Insurance Name/ID (if applicable)

(*) TABS ID

(*) OPWDD Eligibility Diagnosis

Other Diagnosis

(*) Primary Care Provider

(*) Primary Care Provider Address

(*) Primary Care Provider Phone Number

Primary Care Provider Fax Number

Please check preference(s) for Clinic Site (All services are not provided at all sites)

Van Buren (Wayne County)

Redmond (Wayne County)

Washington St (Orleans County)

Academy St (Orleans County)

Elba (Genesee County)

Walnut St (Genesee County)

Lockport (Niagara County)

Niagara Falls Blvd (Niagara County)

Submitter Information

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(*) Submitter Name

(*) Submitter Relationship

(*) Submitter Address

(*) Submitter Phone Number

Submitter Email

Request Programs

Psychology services open to internal applicants only

Article 16 Medical (Dementia Screening, Guardianship, Health Care Proxy)	Article 16 Occupational Therapy	Article 16 Physical Therapy
Article 16 Psychology (Comprehensive Evaluations, Informed Consent - Internal Only)	Article 16 Social Work	Article 16 Social Work Group
Article 16 Speech Language Therapy

Applicant Contact Information

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Demographics

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Files

Life Plan

Pending

OPWDD Eligibility

Pending

Current Medical Reports (Physical Exam, Med Changes, Etc.)

Pending

Psychological Report (outside of agency)

Pending

Any recent evaluations/discharge paperwork from physicians or hospital

Pending

Copy of Medicaid/Insurance Card(s)

Pending

Guardianship Paperwork (if applicable)

Pending