Professional Referral

For use by providers.

You can make a referral several ways. You can call us at 1 (800) 442-1713 or 1 (231) 947-8920.

You can use the fillable form below and submit it electronically. Please do not include any personal health information. We will gather all necessary details when we follow up.

You may download the form at the bottom of this page and fax to (231) 947-6401 or email to [email protected]. If sending through email be sure to encrypt the email to ensure it is sent securely to protect any personal health information you included.

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Professional Referral Form (electronic/fillable)

    Refer someone who needs help, education, or who wants to connect.
    Name of person being referred: *
    What is your relationship to the person you are referring?
    Is the person aware of referral?
    Please tell us what information you are looking for by checking one or more of the boxes below. (must select at least one)
    Referring person's name:
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