Referral Intake Form Generator for the USA

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Key Requirements PROMPT example:

Referral Intake Form

"I need a Referral Intake Form for my mental health practice that includes HIPAA compliance and specific sections for insurance verification, as we'll be accepting both private and Medicare patients starting January 2025."

Document background
The Referral Intake Form is a crucial document used across various sectors in the United States to facilitate and document the transfer of clients between service providers. This standardized form ensures proper documentation of client information, service needs, and referral authorization while maintaining compliance with federal and state regulations. It serves as the initial point of contact between the referring entity and the receiving organization, capturing vital information necessary for service delivery and legal compliance. The form is designed to protect all parties involved by clearly documenting the referral process and maintaining appropriate privacy standards.
Suggested Sections

1. Client Information: Basic contact and demographic information of the person being referred

2. Referral Source: Information about the person/organization making the referral

3. Service Needs: Description of required services or reason for referral

4. Privacy Notice: HIPAA and other privacy notifications

5. Consent: Client authorization for information sharing

Optional Sections

1. Insurance Information: Details of client's insurance coverage, used when services may be billable for medical or healthcare referrals

2. Medical History: Relevant medical information for healthcare-related referrals

3. Emergency Contact: Secondary contact information for high-risk or healthcare services

Suggested Schedules

1. Privacy Policy: Detailed privacy practices and client rights

2. Service Description: Detailed description of available services

3. Required Documentation Checklist: List of additional documents needed to process referral

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Industries

HIPAA: Health Insurance Portability and Accountability Act - Federal law that protects sensitive patient health information from being disclosed without patient consent

GLB Act: Gramm-Leach-Bliley Act - Requires financial institutions to explain their information-sharing practices and protect sensitive data

CCPA: California Consumer Privacy Act - Provides California residents with rights regarding their personal information and imposes obligations on businesses handling that data

Federal Anti-Kickback Statute: Prohibits the exchange (or offer) of anything of value in an effort to induce or reward the referral of federal health care program business

Stark Law: Prohibits physicians from referring patients for certain designated health services to entities with which they have a financial relationship

FTC Regulations: Federal Trade Commission regulations governing fair business practices and consumer protection

ESIGN Act: Federal law ensuring the legal validity of electronic signatures and records in interstate commerce

ADA: Americans with Disabilities Act - Prohibits discrimination against individuals with disabilities and ensures equal access

Civil Rights Act: Prohibits discrimination on the basis of race, color, religion, sex, or national origin

State Privacy Laws: Various state-specific laws governing the collection, use, and protection of personal information

Professional Licensing Requirements: State-specific regulations governing professional qualifications and licensing for various industries

Informed Consent Requirements: Legal requirements for obtaining and documenting valid consent from individuals before collecting or sharing their information

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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