MAT Program

Medication-Assisted Treatment in Your Community

VIP Integrative Healthcare provides medication-assisted treatment (MAT) services.

Referral Form

Client’s Name

Date of Referral

Medicaid ID Number

Address / Usual Location

Birthdate

Telephone Number

Referral To:
VIP INTEGRATIVE HEALTHCARE 3600 Forest Hill Blvd STE 3 B Palm Springs, FL 33406
Referred By: [Service provider’s name, address, and telephone number]

Client's Name

give my permission to

Services provider's Name

to release this information to VIP Integrative Healthcare to be used to assist me in monitoring and coordinating my health care and social service needs.

Signature of client/parent or guardian

Date

Service Provider’s Reply (summary of findings, diagnosis, recommendations, comments, as appropriate):

Signature

Date

MAT Program

MAT Program

Medication-Assisted Treatment in Your Community

Referral Form

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