By submitting this request, I authorize AdaptWell Health, a licensed medical specialist, to evaluate and facilitate the referral as requested. I understand that this referral is being initiated at the patient's request. The information submitted—such as clinical notes, assessments, and contact details—is necessary to support the referral and will be shared with AdaptWell Health accordingly.

All personal health information will be handled in compliance with HIPAA and applicable privacy regulations. Submission of this request does not obligate AdaptWell Health to assume responsibility for the patient’s care or provide treatment.

By checking the box below, I confirm that the patient has provided written consent to share this information for the purpose of care coordination.

I consent to facilitate this referral request to AdaptWell Health in accordance with the patient’s written consent for care coordination.