Cedar Referral Form

If you have questions or trouble filling out this form, please contact RIPIN at 401-270-0101 x365 or email info@ripin.org.

Referral Information

Name of Referrer

Date of referral

Phone Number

Parent/guardian aware of and in full agreement with referral

Yes

Parent 1 Information

Parent/Guardian First Name

Parent/Guardian Last Name

Home Phone Number

Cell Phone Number

Email Address

Interpreter needed?

Preferred Language

Parent 2 Information

Parent/Guardian First Name

Parent/Guardian Last Name

Home Phone Number

Cell Phone Number

Email Address

Interpreter needed?

Preferred Language

Child Information

First Name

Last Name

Date Of Birth

Gender

Child's Social Security Number and/or Medicaid ID information MUST be included to submit form.

Social Security Number

Medicaid ID #

10-digit number found on the child's Anchor card

Street Address

City

State

Postal Code

Primary Care Physician Name

PCP Phone

Primary Health Insurance

Primary Insurance Member ID#

Secondary Health Insurance

Secondary Insurance Member ID#

Child enrolled in Current Care?

Medical DX Codes (if known)

Hold shift to select multiple options.

Chronic Condition requiring Intensive Care Coordination: (Please select all that apply)

Hold shift to select multiple options.

Child/Family Risk Factors: (Please check all that apply)

Hold shift to select multiple options.

Specify other necessary info:

Referral will not be submitted without the child’s Social Security Number or Medicaid ID. Please ensure accuracy before submitting.

Contact Information