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Office for the Advancement of Telehealth - HRSA

UNM Center for Telehealth

 

Services and Referral

REACH Services || Referral Information

Referral for Clinical Consultation

  1. Print the referral to REACH form or fill the form out on-line.
  2. In addition to the REACH referral form, print the on-line form and have the family complete: Informed Consent to Participate in Telehealth Services and fax or mail to REACH.
  3. When the clinical consultation is part of Early Intervention Services, print the on-line form and have the family complete: Prior Notice for Services and fax or mail to REACH.
  4. When medical records are needed for the referral, print the on-line form and have the family complete: Authorization to Request Health Information and fax or mail to medical provider.
  5. When the encounter will be billed, print the on-line form and have the family complete: Insurance/Medicaid Information & Authorization and fax or mail to REACH.

Please use this checklist to ensure you have fully completed the REACH referral.

Referral Forms

Informed Consent Forms



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