1st Care Management transmits all information provided here via secure email to ensure the confidentiality, integrity, and availability of all electronic protected health information that is created, received, maintained, or transmitted pursuant to 45 CFR 164.306 (a)(1).
1st Care Management frequently reviews and modifies the security measures implemented under this subpart as needed to continue provision of reasonable and appropriate protection of electronic protected health information.

Please note that this is only a referral form. The 1CM office will call the referring organisation/person, or the patient, whichever is preferred, to confirm interest in our services, and then ask for patient’s data and history to complete intake. To skip that step, if you are submitting information for yourself or someone else for intake, please go to the online 1CM Intake Form , and a 1CM representative will soon be in touch to establish and plan care.

Please complete the form below.

Patient Information

Patient Information

Name *

Date of Birth *

Phone Number *

Address *

City *

Postal / Zip Code *

Referring Information

Referring Information

Organization

Person’s Name

Insurance ID

Person’s Phone Number

Person’s Email

Before a patient is seen through 1st Care Management, we must have a complete medication list for this patient, Medical History, as well as any current test results.

Before a patient is seen through 1st Care Management, we must have a complete medication list for this patient, Medical History, as well as any current test results.

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If you do not have the above documents, please complete the following fields to allow 1st Care Management to request these documents on your behalf.

If you do not have the above documents, please complete the following fields to allow 1st Care Management to request these documents on your behalf.

Name of any physicians and medical facilities you’ve visits in the last 6 months.

Name of any physicians and medical facilities you’ve visits in the last 6 months.

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Reason for referral

Reason for referral:

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Reason for referral

To confirm interest and/or establish care , 1CM staff should call:

To confirm interest and/or establish care , 1CM staff should call:

Referring Organization

Referring Organization/Person

The patient

Permission to contact: *

I give 1st Care Management permission to contact the above providers to acquire my medical information for the purposes of providing me healthcare services through their agency. *

Security *

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Phone: (833) 633-4778
Fax:     (888) 622-6062
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Address: 1120 Hope Rd Suite 210, Sandy Springs, GA 30350