Your Primecare Contact

Janice Clark

Community Outreach Partner

River Valley AAA Region

Have a question before submitting a referral? Contact your Primecare Community Outreach Partner or complete the form, and our intake team will follow up.

Refer a Client to Primecare

Thank you for trusting Primecare with your referral.  

Use this secure form to provide basic referral details for someone who may need care or support. Once submitted, our service coordination team will review the referral, determine the appropriate next step, and follow up within 24 hours.

Submit a Referral

Please complete the fields below with the information available to you. Clinical documentation is not required at this stage. Our service coordination will collect any additional information needed after the referral is received.

"*" indicates required fields

I. Lead Information

Lead Name

Lead DOB

Zip Code

Phone

Lead Primary Insurance Coverage

Service of Interest

Other Service of Interest

II. Referrer Information

Referral Source Organization Type

Referral Organization Name

Referral Name

Preferred Case Management Company

If you don't have a preferred case management company, please leave the field empty.

Additional Notes

Consent*

REFERRAL FORM DISCLAIMERS AND PRIVACY NOTICE
Information Scope and Submission Guidelines

Important — Referral Form Limitations. This online referral form is designed to collect basic contact and referral information only. Do not include any of the following in this form:

1. Medical diagnoses, treatment histories, or clinical assessments
2. Complete medical records, physician notes, or test results
3. Social Security numbers
4. Insurance identification numbers, policy numbers, or member IDs
5. Detailed clinical information, medication lists, or laboratory values
6. Financial account information
7. Other sensitive personal health information protected under HIPAA

Submission of detailed protected health information through this form may delay processing of your referral. Our team will contact you to obtain any additional clinical information needed through secure, HIPAA-compliant channels.
Use of Information. The information you submit through this referral form will be received and reviewed by our intake team and service coordinators for the purpose of evaluating the referral, contacting the individual or family for additional information, and determining appropriate next steps in the intake and eligibility assessment process.
No Guarantee of Services. Submission of this referral form does not guarantee eligibility for services, admission to any program, or acceptance into our organization. All referrals are subject to clinical review, eligibility verification, and capacity availability. You will be contacted by our team regarding the status of this referral and any additional steps required.
Emergency Disclaimer. This referral form is not monitored in real time and is not intended for use in emergency situations. If you or the individual being referred is experiencing a medical emergency or urgent psychiatric crisis, do not use this form. Instead:

1. Call 911 for immediate emergency medical or psychiatric assistance, or
2. Go directly to the nearest hospital emergency department, or
3. Contact the Georgia Crisis and Access Line (GCAL) at 1-800-715-4225 or the Indiana Crisis and Access Line at 988 within Indiana (available 24/7 for mental health and substance use crises), or
4. Contact the individual's primary care provider or treating physician for urgent medical concerns

Privacy and Confidentiality. We are committed to protecting the privacy and confidentiality of the information you provide in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and Georgia state privacy laws. Information submitted through this form will be maintained securely and will be disclosed only as necessary to evaluate the referral, coordinate care, or as otherwise permitted or required by law. For more information about how we use and protect health information, please see our Notice of Privacy Practices available at https://primecarehomecare.com/privacy-policy/.

Questions. If you have questions about this referral form, our intake process, or our privacy practices, please contact our Referral Intake Department at 478-345-0523.

I certify that the information I have provided is accurate to the best of my knowledge. I have read and agree to the Referral Form Disclaimers and Privacy Notice and understand that submitting this form does not guarantee eligibility for services or establish a provider-client relationship. I authorize the organization to contact me regarding my inquiry by phone, email, or text message.*

Privacy Notice: Our intake team and service coordinators will use the information submitted to follow up on this referral and determine next steps. Submission of this form does not guarantee eligibility, admission, or acceptance for services. This form is not for emergencies. For urgent medical needs, call 911 or contact the appropriate medical provider directly.

What Happens Next

Referral Submitted

Your referral is securely sent to the Primecare Service Coordination / Intake team.

Intake Review

Our team reviews the information provided and determines the appropriate next step.

Follow-Up Within 24 Hours

A member of our Intake team will follow up to gather any additional information and guide the referral forward.

Referral Form Disclaimers and Privacy Notice

Information Scope and Submission Guidelines

Important — Referral Form Limitations. This online referral form is designed to collect basic contact and referral information only. Do not include any of the following in this form:

Medical diagnoses, treatment histories, or clinical assessments
Complete medical records, physician notes, or test results
Social Security numbers
Insurance identification numbers, policy numbers, or member IDs
Detailed clinical information, medication lists, or laboratory values
Financial account information
Other sensitive personal health information protected under HIPAA

Submission of detailed protected health information through this form may delay processing of your referral. Our team will contact you to obtain any additional clinical information needed through secure, HIPAA-compliant channels.

Privacy Notice

Use of Information. The information you submit through this referral form will be received and reviewed by our intake team and service coordinators for the purpose of evaluating the referral, contacting the individual or family for additional information, and determining appropriate next steps in the intake and eligibility assessment process. No Guarantee of Services. Submission of this referral form does not guarantee eligibility for services, admission to any program, or acceptance into our organization. All referrals are subject to clinical review, eligibility verification, and capacity availability. You will be contacted by our team regarding the status of this referral and any additional steps required. Emergency Disclaimer. This referral form is not monitored in real time and is not intended for use in emergency situations. If you or the individual being referred is experiencing a medical emergency or urgent psychiatric crisis, do not use this form. Instead:

Call 911 for immediate emergency medical or psychiatric assistance, or
Go directly to the nearest hospital emergency department, or
Contact the Georgia Crisis and Access Line (GCAL) at 1-800-715-4225 or the Indiana Crisis and Access Line at 988 within Indiana (available 24/7 for mental health and substance use crises), or
Contact the individual’s primary care provider or treating physician for urgent medical concerns

Privacy and Confidentiality. We are committed to protecting the privacy and confidentiality of the information you provide in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and Georgia state privacy laws. Information submitted through this form will be maintained securely and will be disclosed only as necessary to evaluate the referral, coordinate care, or as otherwise permitted or required by law. For more information about how we use and protect health information, please see our Notice of Privacy Practices available at https://primecarehomecare.com/privacy-policy/. Questions. If you have questions about this referral form, our intake process, or our privacy practices, please contact our Referral Intake Department at 478-345-0523.