Referral

To refer a patient Compassion Health Services LLC, please fill out this secure form. We’ll use the patient’s information to outreach them, and your information to share progress updates.

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Name *

First

Last

Patient Contact Email *

example@gmail.com

Patient Smartphone Number *

Please enter a valid phone number.

State *

Referring Contact Name* *

First

Last

Referring Contact Email *

example@gmail.com

Referring Medical Group or Referring Organization (if any)

Notes (optional)

Submit Referral

By submitting this form, I understand that Compassion Health Services LLC is an outpatient telemedicine-based opioid use disorder provider. Compassion Health Services LLC can treat most patients with opioid use disorder as long as they meet the following criteria:

• Over 18 years old
• Has a photo ID
• Has a smartphone
• Consents to telemedicine care
• Has a safe place to store medication
• Is not on Methadone, or on less than 40mgs of Methadone

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