Services

Referral Form

Apply for services from Plains Area Mental Health Center with our convenient online form. Our team will contact you as soon as possible with the next steps.

Referral Source Information

Name/Agency
Phone
Email
Is the patient aware of this referral?

Patient Information

Name

Date of Birth
Phone

Legal Address
City
State
Zip Code

Current Address/Location Please complete this section if the patient is living at a different location than their legal address.
City
State
Zip Code

Preferred Language
Are translation services needed?

Parent/Legal Guardian Information

This section should be completed if the patient is a minor or adult under legal guardianship.

Guardian Name
Guardian Address
City
State
Zip Code

Guardian Phone

Does the patient have an active court order?

Please attach a copy of the court order.

Insurance Information

Managed Care Organization
Iowa Total Care
Wellpoint
Molina
Iowa Medicaid Enterprise (IME)
Other Insurance
If other insurance, please list:

Insurance and Group #
MCO #

Diagnosis Information

Physical Health Diagnoses Please list ICD-10 codes.
Does patient have a primary care physician?
If yes, please list the Primary Care Provider's name or agency

Mental Health Diagnoses Please list ICD-10 codes.
Who was the diagnosing mental health provider and agency? Please include credentials.

Other Information

Reason for Referral
Services Requested What services provided by Plains Area Mental Health Center are being requested for the patient?
Supports Involved Examples: Iowa Vocational Rehabilitation Services, Mental Health & Disability Services Region, Juvenile Court Officer, therapy, payee, etc.
Preferred Location
Other Pertinent Information