REFERRAL FORM 1728 5th Ave. North, Birmingham, Alabama 35203 Company Number: 205. 502.7278 Fax Number: 205.502.7779 Referral Form Contact Information Perspective Consumer Name Address Phone Number Mobile Number Email Medical Information Medicaid Number: —Please choose an option—Yes, please explain belowNo Has this person ever been diagnosed with a mental illness ? If answer was Yes, please explain: —Please choose an option—Yes, please explain belowNo Are you an Alabama Resident? If answer was Yes, please explain: Reason for Referral Please send over an ESPDT Referral form from you primary care physician to accompany your referral form.
