Minnesota CarePartner

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call: 612.289.5656  |  email: info@mncarepartner.com

 

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You are here: Home / Make a Referral to Roots Recovery

Make a Referral to Roots Recovery

Make a Referral for Substance Use/Addiction Treatment at Roots Recovery

Roots Recovery Referral Form

Step 1 of 2

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  • Instructions

    Please complete this form to the best of your ability. 

    Please upload a release of information signed by the client to the upload link at the end of this form.

    For your convenience, we offer several convenient options for providing releases of information:

    1. Fillable PDF versions of our release form is linked at the bottom of this form. The PDF forms can be uploaded to this page, emailed to roots@mncarepartner.com, or faxed to 612.564.5932.
    2. A fully electronic version of our release is available at https://mncarepartner.com/signrootsroi  This link can be given to the client for completion on any computer or mobile device. We will be notified once the release is signed
  • Referent Information

    You can skip this section if you are the client!
  • Date Format: MM slash DD slash YYYY


  • Client Information

  • for insurance verification


  • Insurance/Payer Information

  • We currently only accept the funding sources listed below. Please contact us at 612.564.5933 with questions.


  • Client Needs

  • Check all that apply
  • Check all that apply
  • This may include the need for an interpreter, the desire for a provider from a specific culture, etc.


  • Additional Information & File Upload

  • Please attach below or fax to 612.564.5932 attention Intake
  • Please provide any more information you feel is pertinent to help us process this referral and effectively deliver services to this client.
  • Upload any DA, release of information, court/CPS records, or other pertinent information
    Drop files here or

Contact

call: 612-289-5656
email: info@mncarepartner.com
fax: 651-925-0278

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