{"id":7936,"date":"2026-08-06T17:43:30","date_gmt":"2026-08-06T17:43:30","guid":{"rendered":"https:\/\/medcare.org\/?page_id=7936"},"modified":"2026-08-13T12:02:21","modified_gmt":"2026-08-13T12:02:21","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/medcare.org\/es\/refer-a-patient\/","title":{"rendered":"Refer a patient"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"7936\" class=\"elementor elementor-7936\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-289057b e-flex e-con-boxed e-con e-parent\" data-id=\"289057b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5d62055 elementor-widget elementor-widget-text-editor\" data-id=\"5d62055\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-66d4d1e0 e-grid e-con-boxed e-con e-parent\" data-id=\"66d4d1e0\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_top&quot;:&quot;drops&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-shape elementor-shape-top\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" height=\"100%\" viewbox=\"0 0 283.5 27.8\" preserveaspectratio=\"xMidYMax slice\">\n\t<path class=\"elementor-shape-fill\" d=\"M0 0v1.4c.6.7 1.1 1.4 1.4 2 2 3.8 2.2 6.6 1.8 10.8-.3 3.3-2.4 9.4 0 12.3 1.7 2 3.7 1.4 4.6-.9 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0-.1.1-.1.2-.2.4-.3.7-.4.8v.1c-.1.2-.1.2 0 0v-.1l.4-.8c0-.1.1-.1.1-.2.2-.4.5-.8.8-1.2V0H0zM282.7 3.4z\"\/>\n<\/svg>\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-37109e7b e-con-full e-flex e-con e-child\" data-id=\"37109e7b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e3f394b elementor-widget elementor-widget-heading\" data-id=\"e3f394b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">1<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6cf7f112 elementor-widget elementor-widget-heading\" data-id=\"6cf7f112\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Submit the Referral Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-14cea2fa elementor-widget elementor-widget-text-editor\" data-id=\"14cea2fa\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\"><span style=\"color: #000;\">Easily submit our secure referral form with essential patient details and primary caregiver or provider contact information to initiate specialized senior telehealth services<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-13b1dbe e-con-full e-flex e-con e-child\" data-id=\"13b1dbe\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4e32008 elementor-widget elementor-widget-heading\" data-id=\"4e32008\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">2<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6d5c261 elementor-widget elementor-widget-heading\" data-id=\"6d5c261\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">We Reach Out &amp; Verify Eligibility<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-64e548b elementor-widget elementor-widget-text-editor\" data-id=\"64e548b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: left;\"><span style=\"color: #000;\">Dedicated care coordinators review Medicare and insurance eligibility within 24 hours, reaching out directly to connect older adults with experienced telehealth clinicians and geriatric care specialists<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-0133f81 e-con-full e-flex e-con e-child\" data-id=\"0133f81\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-be939f9 elementor-widget elementor-widget-heading\" data-id=\"be939f9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">3<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-33e0c39 elementor-widget elementor-widget-heading\" data-id=\"33e0c39\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Personalized Care Consultation<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3a9c704 elementor-widget elementor-widget-text-editor\" data-id=\"3a9c704\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\"><span style=\"color: #000;\">Patients participate in a comprehensive remote consultation to evaluate health goals, address social determinants of health (SDOH), and match with participating Medicare-certified practitioners<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-05c3acc e-con-full e-flex e-con e-child\" data-id=\"05c3acc\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-65e12f3 elementor-widget elementor-widget-heading\" data-id=\"65e12f3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">4<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-45aa2d6 elementor-widget elementor-widget-heading\" data-id=\"45aa2d6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Tailored CHI Care Coordination<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3ea3859 elementor-widget elementor-widget-text-editor\" data-id=\"3ea3859\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\"><span style=\"color: #000;\">Upon clinical evaluation, qualified community health workers coordinate ongoing virtual care management, link seniors to vital community resources, and optimize continuous remote health 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id=\"formTitleId\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Submit a Community Health Referral<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-265f0cf elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"265f0cf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-64bacf3 elementor-widget elementor-widget-text-editor\" data-id=\"64bacf3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"color: #136d5b;\">Easily refer your patient for specialized community<br \/>care. Fill out the secure form below to ensure fast, coordinated support.<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e3e7b8f elementor-widget elementor-widget-text-editor\" data-id=\"e3e7b8f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>\n<section class=\"msrf-refer-section\">\n\t<div class=\"msrf-refer-inner\">\n\t\t<div class=\"msrf-refer-card\">\n\t\t\t<div id=\"msrf-response\" class=\"msrf-response\" role=\"alert\" aria-live=\"polite\"><\/div>\n\n\t\t\t<form id=\"msrf-refer-form\" class=\"msrf-form\" novalidate action=\"\">\n\n\t\t\t\t\n\t\t\t\t\t<fieldset class=\"msrf-fieldset\">\n\t\t\t\t\t\t<legend class=\"msrf-legend\">Patient Information<\/legend>\n\n\t\t\t\t\t\t<div class=\"msrf-grid\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_patient_first_name\">\n\t\t\t\t\t\t\t\t\t\tPatient first name\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_patient_first_name\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_patient_first_name\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"Juan\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_patient_first_name_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_patient_last_name\">\n\t\t\t\t\t\t\t\t\t\tPatient last name\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_patient_last_name\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_patient_last_name\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"Oso\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_patient_last_name_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_patient_dob\">\n\t\t\t\t\t\t\t\t\t\tFecha de nacimiento\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"date\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_patient_dob\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_patient_dob\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"\"\n\t\t\t\t\t\t\t\t\t\t\tautocomplete=\"bday\"\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_patient_dob_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_patient_phone\">\n\t\t\t\t\t\t\t\t\t\tPatient phone number\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"tel\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_patient_phone\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_patient_phone\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"(555) 123-4567\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_patient_phone_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group msrf-group--full\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_patient_email\">\n\t\t\t\t\t\t\t\t\t\tPatient email address\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"email\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_patient_email\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_patient_email\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"john@example.com\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_patient_email_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group msrf-group--full\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_insurance\">\n\t\t\t\t\t\t\t\t\t\tInsurance type\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<select\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_insurance\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_insurance\"\n\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\t\t<option value=\"\">Select one&#8230;<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Original Medicare (Part A &amp; Part B)\">\n\t\t\t\t\t\t\t\t\t\t\t\t\tOriginal Medicare (Part A &amp; Part B)\t\t\t\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Medicare Advantage (Part C)\">\n\t\t\t\t\t\t\t\t\t\t\t\t\tMedicare Advantage (Part C)\t\t\t\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Medicare &amp; Medicaid (Dual Eligible)\">\n\t\t\t\t\t\t\t\t\t\t\t\t\tMedicare &amp; Medicaid (Dual Eligible)\t\t\t\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Medicaid only\">\n\t\t\t\t\t\t\t\t\t\t\t\t\tMedicaid only\t\t\t\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Private \/ Employer insurance\">\n\t\t\t\t\t\t\t\t\t\t\t\t\tPrivate \/ Employer insurance\t\t\t\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"No insurance\">\n\t\t\t\t\t\t\t\t\t\t\t\t\tNo insurance\t\t\t\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"Not sure\">\n\t\t\t\t\t\t\t\t\t\t\t\t\tNot sure\t\t\t\t\t\t\t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_insurance_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group msrf-group--full\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_reason\">\n\t\t\t\t\t\t\t\t\t\tReason for referral\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<textarea\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_reason\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_reason\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"Diagnosis, symptoms, requested service\u2026\"\n\t\t\t\t\t\t\t\t\t\t\trows=\"4\"\n\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t><\/textarea>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_reason_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><!-- \/msrf-grid -->\n\t\t\t\t\t<\/fieldset>\n\n\t\t\t\t\n\t\t\t\t\t<fieldset class=\"msrf-fieldset\">\n\t\t\t\t\t\t<legend class=\"msrf-legend\">Referral Source Information<\/legend>\n\n\t\t\t\t\t\t<div class=\"msrf-grid\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_provider_name\">\n\t\t\t\t\t\t\t\t\t\tSu nombre\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_provider_name\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_provider_name\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"Dr. Jane Smith\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_provider_name_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_practice_name\">\n\t\t\t\t\t\t\t\t\t\tPractice \/ facility name\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_practice_name\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_practice_name\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"Downtown Family Clinic\"\n\t\t\t\t\t\t\t\t\t\t\tautocomplete=\"organization\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_practice_name_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_provider_email\">\n\t\t\t\t\t\t\t\t\t\tTu direcci\u00f3n de correo electr\u00f3nico\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"email\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_provider_email\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_provider_email\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"jane.smith@example.com\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_provider_email_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_provider_phone\">\n\t\t\t\t\t\t\t\t\t\tYour phone number\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"msrf-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\t\t\ttype=\"tel\"\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_provider_phone\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_provider_phone\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"(555) 987-6543\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired aria-required=\"true\"\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_provider_phone_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-group msrf-group--full\">\n\n\t\t\t\t\t\t\t\t\t<label for=\"msrf_notes\">\n\t\t\t\t\t\t\t\t\t\tAdditional notes\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<textarea\n\t\t\t\t\t\t\t\t\t\t\tid=\"msrf_notes\"\n\t\t\t\t\t\t\t\t\t\t\tname=\"msrf_notes\"\n\t\t\t\t\t\t\t\t\t\t\tplaceholder=\"Any additional information that may help us prepare for this patient\u2026\"\n\t\t\t\t\t\t\t\t\t\t\trows=\"4\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t><\/textarea>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_notes_error\"><\/span>\n\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><!-- \/msrf-grid -->\n\t\t\t\t\t<\/fieldset>\n\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"msrf-consent-row\">\n\t\t\t\t\t\t<div class=\"msrf-consent\">\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"checkbox\"\n\t\t\t\t\t\t\t\tid=\"msrf_consent\"\n\t\t\t\t\t\t\t\tname=\"msrf_consent\"\n\t\t\t\t\t\t\t\tvalue=\"1\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t<label for=\"msrf_consent\" class=\"msrf-consent__text\">\n\t\t\t\t\t\t\t\tI confirm that I have this patient&#8217;s permission to share their information with Medcare for the purpose of this referral, and that I have read and agree to Medcare&#8217;s <a href=\"\/privacy-policy\/\" target=\"_blank\" rel=\"noopener\">Pol\u00edtica de Privacidad<\/a> y <a href=\"\/terms-of-service\/\" target=\"_blank\" rel=\"noopener\">T\u00e9rminos de Servicio<\/a>.\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_consent_error\"><\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t<div class=\"msrf-form-bottom\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"msrf-recaptcha-wrap\">\n\t\t\t\t\t\t\t<div\n\t\t\t\t\t\t\t\tclass=\"g-recaptcha\"\n\t\t\t\t\t\t\t\tdata-sitekey=\"6LePU2AsAAAAAB3hxYQwc2m54giPEK3MWeR5kPoM\"\n\t\t\t\t\t\t\t><\/div>\n\t\t\t\t\t\t\t<span class=\"msrf-field-error\" id=\"msrf_recaptcha_error\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"bloc_submit\">\n\t\t\t\t\t\t<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"SUBMIT REFERRAL\">\n\t\t\t\t\t\t<span class=\"wpcf7-spinner\"><\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<input type=\"hidden\" name=\"trp-form-language\" 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