REFERRAL FORM

Start a care coordination request.

Share basic, non-sensitive referral details below. Our Care Network Director will review the request and follow up to help organize appropriate next steps. For urgent discharges or details that should be discussed directly, please call (818) 574-3333.

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Referring Party

Your name *

Role / title

Organization

Phone *

Email *

Patient Information

This online referral form is intended for adult patients age 18 or older.

Patient name *

Age

Funding / insurance type

Service needed

Preferred location / zip

Urgency

Care Needs & Situational Notes

Notes

I understand this form is for basic referral information related to care coordination and resource navigation. It is not for emergencies, medical advice, clinical assessments, or submission of detailed protected health information.

I confirm that I am authorized to submit this referral and authorize Prime Care Link to use the information provided to respond to the request and, when needed, share relevant basic referral information with potential care providers, facilities, or service organizations for care-navigation and coordination purposes.

Do not include detailed protected health information. For emergencies, call 911. For urgent or sensitive details, call (818) 574-3333.

Prime Care Link helps coordinate access to healthcare providers, care services, placement options, and community resources. We do not provide clinical care, medical advice, clinical assessments, or emergency services, and we do not make clinical, admission, placement, or service decisions. Final decisions remain with the patient, family, legal representative, and licensed healthcare providers.