Consultation Request Form
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1MARYLAND BEHAVIORAL HEALTH IN PEDIATRIC PRIMARY CARE (B-HIPP)
CONSULTATION REQUEST FORM
Date: __ /__ / ____
Provider Information
Provider Name:
Practice Name:
Consultation Question
Please describe your question including any relevant clinical information (e.g., medications, current treatment plan):
If your question is case specific, please complete the Case Information section below. If not, please jump to Contact Preferences.
Case Demographic Information
Age:
Sex:
Male
Female
Other
Race (select all that apply):
African-American
American Indian
Asian
Caucasian
Native Hawaiian/Pacific Islander
Other (please specify):
Hispanic or Latino?
Yes
No
Contact Preferences
What is the best number to reach you?
What is the best time to call you back?
PLEASE FAX TO OUR HIPAA COMPLIANT LINE: 1-855-MD-BHIPP (1-855-632-4477)
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