Today M-D-Y TIMESTAMP-USF Reporting
[Historical] Client ID (DO NOT USE)
(historical data only - prior to 7/1/2023)
UF - Gainesville UF - Pensacola
Behavioral health hub site.
Date Referral Paperwork Received
* must provide value
Today M-D-Y This date is NOT reported to USF, internal info only.
Fax REDCap REF929 REF change - CAN 922 REF change - Child Psych 80 REF change - Peds B&D 119 REF change - Psychology 890 REF change - Adult Psych 91 REF change - multiple Secure Email Epic Secure Chat
In what way was the referral received?
Date of Referral
* must provide value
Today M-D-Y Date the client was referred by the PCP to the BHH
Paperwork Receipt to Referral
View equation
Due Date for: Patient Satisfaction Survey/Discharge
Today M-D-Y
Due Date for: 6-month Follow-Up
Today M-D-Y
Name of individual submitting referral
* must provide value
The name of the person completing this online form.
Phone Number of individual submitting referral
* must provide value
The ph# of the person completing this online form.
Email Address of individual submitting referral
The email of the person completing this online form.
Practice Name of Referring Provider
* must provide value
Practice Zip Code
* must provide value
Zip code where the referring PCP is located
24/7 Pediatric Care Centers - Jacksonville A Family Place & Pediatrics Absolute Health Advanced Pediatric Center Advent Health All Pediatric Care Alliance Pediatrics American Family Medical Archer Family Health Ascension Ascension - Community Health Northwest Florida Ascension - Pace Pediatrics Ascension Medical Group Sacred Heart at Northside Ascension Medical Group Sacred Heart at Ocean Park Ascension Medical Group Sacred Heart at Watersound Ascension Medical Group Sacred Heart Gulf Breeze Ascension Medical Group Sacred Heart Pediatrics at Cordova Ascension Medical Group Sacred Heart Pediatrics at Pea Ridge Ascension Medical Group Sacred Heart Pediatrics at Perdido Ascension Medical Group Sacred Heart Pediatrics at Port St Joe Ascension Medical Group Sacred Heart Primary Care - Panama City Beach Ascension Medical Group St. Vincent's Pediatrics - Jacksonville Beach Ascension Sacred Heart - Gulf Breeze Ascension Sacred Heart Pediatric Care Center At Gulf Breeze Ascension Sacred Heart Pensacola Ascension Sacred Heart Pensacola / UF Health Women's Care Ctr Ascension Sacred Heart Primary Care Lynn Haven Aza Health & Wellness Baldwin Pediatrics Baptist Hospital Baptist Medical Group Family Medicine & Walk-In Care - Pace Baptist Medical Group Primary Care - Gulf Breeze Baptist Medical Group Primary Care - Live Oak Baptist Primary Care - Murabella Benton Pediatrics (Privia Health) Breen Health Capernaum Medical Center Cardinal Healthcare Carither's Pediatric Group Celebrate Primary Care Century Medical Center Century Pediatrics Chiefland Medical Center Child Neurology Center of Orlando Children's Clinic of Pensacola Children's Health of Ocala Chipola Medical Associates Chipola Surgical & Med - Family & Internal Medicine Chipola Surgical & Med - Family Practice w/Obstetrics Chipola Surgical & Med - Panhandle Family Care Family Practice Chipola Surgical and Medical Specialties- Pediatrics Citrus County Schools Community Health Northwest Florida Doctors' Memorial Hospital Steinhatchee Family Medicine Dr. B's Kids Elite DNA Express Care of Belleview Family Care Specialists FSU Future Pediatrics Gainesville Family Physicians Gainesville Pediatric Associates Gainesville Pediatric Medicine Grace Pediatrics Halifax Behavioral Services Healthy Steps Pediatrics Heart of Florida Health High Springs Pediatrics Jacksonville Pediatric Associates Jacobson Pediatrics Jay Medical Clinic Kids Care Pediatrics (Palatka) Kids Doc Pediatrics Kids Health Alliance Kidz Care Pediatrics (Hudson, near Tampa) Langley Health Services - Crystal River Langley Health Services - Homosassa Langley Health Services - Inverness Langley Health Services - Lecanto Langley Health Services - Ocala Langley Health Services - Sumterville Leesburg Pediatrics Lifespan Psychiatric Services of N FL Lighthouse Pediatrics Little Pine Pediatrics Lynn Keefe, MD Pediatrics Magnolia Pediatrics Marion Pediatrics Merchant Pediatrics Milestones Pediatrics Nation's Best Family Health Care in Panama City Nemours Children's Health Nemours Primary Care North Florida Family Medicine North Florida Pediatrics Ocala Family Care Ocala Family Medical Center Ormond Pediatrics Palms Medical Group - Bell Palms Medical Group - Branford Palms Medical Group - Chiefland Palms Medical Group - Fleming Island Palms Medical Group - Gainesville Palms Medical Group - High Springs Palms Medical Group - Lake City East Palms Medical Group - Lake City West Palms Medical Group - Live Oak Palms Medical Group - Orange Park Palms Medical Group - Starke Palms Medical Group - Trenton Palms Medical Group - Williston PanCare PanCare Health - Blountstown (Calhoun County) PanCare Health - Bonifay (Holmes County) PanCare Health - Bristol (Liberty County) PanCare Health - Chipley (Washington County) PanCare Health - Freeport (Walton County) PanCare Health - Gulf Coast State College Clinic (Bay County) PanCare Health - Malone (Jackson County) PanCare Health - Marianna (Jackson County) PanCare Health - Panama City Medical (Bay County) PanCare Health - Port St. Joe (Gulf County) Panhandle Rural Health & Primary Care Pediatric & Internal Medicine Specialists (PedIM Healthcare) Pediatric Associates - Jacksonville/Main Street Pediatric Associates - Ocala Pediatric Associates - Plantation Pediatric Convenient Care Pediatric Services and Breathing Center, P.A. Pensacola Campus FSU COM Pensacola Christian College Pensacola Pediatrics Pensacola Pediatrics at Cordova Pensacola Pediatrics at Milton Pensacola Pediatrics at Navarre Pensacola Pediatrics at Nine Mile Pensacola Pediatrics at Pace Pensacola Pediatrics at Scenic Hills Pensacola Pediatrics at Tiger Point Premier Medical Associates - The Villages (Santa Barbara Blvd) Premier Pediatrics Professional Park Pediatrics Rainbow Pediatrics (Panama City) Rainbow Pediatrics Center (Jacksonville) SMA Healthcare Sun Country Pediatrics Sunshine Pediatrics Sushil Puskur, MD Psychiatry Tallahassee Medical Group Tallahassee Primary Care Associates Trinity Pediatrics UF Health Hospital / Emergency Dept UF Allergy UF Cardiology UF Dermatology UF Family Medicine UF Health Adolescent and Young Adult Practice UF Health Archer Family Health Care UF Health C.B. McIntosh Center - Jacksonville UF Health Care One Clinic UF Health Community and Family Medicine - Jacksonville UF Health Family Medical Group - Starke UF Health Family Medicine - Amelia Island UF Health Family Medicine - Augustine Oaks UF Health Family Medicine - Brentwood UF Health Family Medicine - Callahan UF Health Family Medicine - Commonwealth UF Health Family Medicine - Crystal Springs UF Health Family Medicine - Eastside UF Health Family Medicine - Haile Plantation UF Health Family Medicine - Jonesville UF Health Family Medicine - Kernan Square UF Health Family Medicine - Lem Turner UF Health Family Medicine - Magnolia Parke UF Health Family Medicine - Main UF Health Family Medicine - Merrill Road UF Health Family Medicine - Monument Landing UF Health Family Medicine - Murray Hill UF Health Family Medicine - Normandy UF Health Family Medicine - Ocala Heath Brook UF Health Family Medicine - Ponte Vedra Beach UF Health Family Medicine - San Jose UF Health Family Medicine - Springhill UF Health Family Medicine - Wildlight UF Health Family Medicine and Pediatrics - Baymeadows UF Health Family Medicine and Pediatrics - Blanding UF Health Family Medicine and Pediatrics - Elizabeth G. Means Center UF Health Family Medicine and Pediatrics - New Berlin UF Health Family Medicine and Pediatrics - Nocatee UF Health Family Medicine and Pediatrics - Oakleaf UF Health General Medicine - Jacksonville UF Health General Medicine - North UF Health Internal Medicine - Deerwood Park UF Health Internal Medicine - Medical Plaza UF Health Internal Medicine - Springhill UF Health Internal Medicine - Kanapaha (formerly Tower Hill) UF Health Pediatric Specialist Tower at Ascension Sacred Heart UF Health Pediatrics - Gerold L. Schiebler CMS Center UF Health Pediatrics - Magnolia Parke UF Health Pediatrics - Millhopper UF Health Pediatrics - North UF Health Pediatrics - Ocala UF Health Pediatrics - San Jose UF Health Pediatrics - Tioga UF Health Pediatrics - Tower Square UF Health Sleep Center UF Health Total Care Clinic - Jacksonville UF Internal Medicine UF Mobile Outreach Clinic UF Pediatric Gastroenterology UF Pediatric Immunology/Rheumatology UF Pediatric Neurology UF Pediatrics UF Psychiatry / Psychology UF Student Health UF Women's Center Village Doctors - Keystone Heights North Village Doctors - Keystone Heights South Village Doctors - Lake Butler Village Doctors - Starke West Florida Pediatrics White Wilson Medical Center - Crestview White Wilson Medical Center - DeFuniak Springs White Wilson Medical Center - Destin White Wilson Medical Center - Fort Walton Beach White Wilson Medical Center - Navarre White Wilson Medical Center - Niceville Williston Pediatrics
Please email Stephanie to add a new Practice to the selection if the referring practice above is not listed here.
Referring Provider (PCP)
* must provide value
Name of referring practitioner (First Name Last Name, do not include credentials)
Discipline
* must provide value
Pediatrician Family medicine OB/GYN Internal medicine APN/NP Certified Nurse Midwife Physician Assistant Psychiatrist Developmental-Behavioral Pediatrician Nurse BH Clinician Care Coordination/Navigator Other
Medical discipline of the practitioner who referred the patient
PCP's discipline if not indicated in options
Enrolled
* must provide value
Yes
No
Is the PCP who referred the client enrolled with the BHH?
Patient's MRN
* must provide value
Patient's (Epic/Creekside) Medical Record Number
Patient's Last Name
* must provide value
Patient's Last Name
Patient's First Name
* must provide value
Patient's First Name
Patient's Date of Birth
* must provide value
Today M-D-Y Patient's DOB
Patient's Age at Referral
View equation
0-5 years 6-11 years 12-17 years 18-21 years
Patient's Gender
* must provide value
Female Male Transgender/non-binary Unknown
Patient's gender
PRIOR TO 10/1/2023 changes: Patient's Race-Ethnicity
* must provide value
Asian Black/African American Hispanic/Latinx Middle Eastern Native American/Alaska Native Native Hawaiian/Pacific Islander White Other Multi-racial Declined to Answer
Patient's race or ethnicity
PRIOR TO 10/1/2023 changes: Patient's Race-Ethnicity (write-in)
Patient's race or ethnicity if not indicated in options
Patient's Race
* must provide value
Asian Black/African American American Indian/Alaska Native Native Hawaiian/Pacific Islander White Other Multi-racial Unknown Declined to Answer
Patient's race
Patient's Race (write-in)
Patient's race if not indicated in options
Patient's Ethnicity
* must provide value
Hispanic/Latinx Not Hispanic/Latinx Unknown Declined to answer
Patient's ethnicity
LEAVE BLANK
Insurance
* must provide value
Private Medicaid/Public Uninsured Other/Don't Know
Patient's insurance provider type
Aetna Better Health (COV) Amerihealth (PRS) Community Care Plan (CCP) Florida Community Care (FCC) Humana Medical Plan (HUM) Molina Healthcare (MOL) Simply Healthcare (SHP) Sunshine Health (SUN) United Healthcare (URS) Children's Medical Services Plan Clear Health Alliance - HIV/AIDS Molina Serious Mental Illness (SMI) Sunshine Serious Mental Illness (SMI) Sunshine Health Child Welfare (CW) Straight Medicaid (Fee for Service/Share of Cost) Unknown
MMA Plan
Populate ONLY if PRIVATE INSURANCE
Patient's Insurance Policy#/Grp#
Patient's Insurance Subscriber Name/DOB
Patient's Phone Number
* must provide value
Patient's Phone Number
Patient's Email Address
Reason for Contact
* must provide value
Teleconsultation only Care coordination support only Both teleconsultation and care coordination
PCP's reason for contacting BHH
Please let us know your general availability for a brief, typically less than 15 minute, telephonic doc to doc.
Reason for Referral
* must provide value
Please specify the reason for requesting this consult
Re-referral
* must provide value
No (new client) Yes
A re-referral is any patient being referred to the Hub that has also been discharged (meaning the follow-up tab has been completed) by the Hub prior to the current referral
PSC-17 Scores ( I = __, A = __, E = __ , Total = __ )
* must provide value
PHQ GAD MDQ SCARED CRAFFT Vanderbilt SNAP IV CSSRS CMRS PRAPARE McLean Personality screener CATS DSM-V ASD Checklist AQ-10 R-MOAS SRS RBQ-3 MCHAT K-BIT EAT-26 SWYC 12 SWYC 24 SWYC 36 SWYC 48 CY-BOCS ASRS Other N/A PSC-17 - DO NOT USE, record on PSC-17 tab
Name of other standardized, validated mental/behavioral health screening tool completed by the PCP other than PSC-17
PHQ GAD MDQ SCARED CRAFFT Vanderbilt SNAP IV CSSRS CMRS PRAPARE McLean Personality screener CATS DSM-V ASD Checklist AQ-10 R-MOAS SRS RBQ-3 MCHAT K-BIT EAT-26 SWYC 12 SWYC 24 SWYC 36 SWYC 48 CY-BOCS ASRS Other N/A PSC-17 - DO NOT USE, record on PSC-17 tab
Name of other standardized, validated mental/behavioral health screening tool completed by the PCP other than PSC-17
PHQ GAD MDQ SCARED CRAFFT Vanderbilt SNAP IV CSSRS CMRS PRAPARE McLean Personality screener CATS DSM-V ASD Checklist AQ-10 R-MOAS SRS RBQ-3 MCHAT K-BIT EAT-26 SWYC 12 SWYC 24 SWYC 36 SWYC 48 CY-BOCS ASRS Other N/A PSC-17 - DO NOT USE, record on PSC-17 tab
Name of other standardized, validated mental/behavioral health screening tool completed by the PCP other than PSC-17
PHQ GAD MDQ SCARED CRAFFT Vanderbilt SNAP IV CSSRS CMRS PRAPARE McLean Personality screener CATS DSM-V ASD Checklist AQ-10 R-MOAS SRS RBQ-3 MCHAT K-BIT EAT-26 SWYC 12 SWYC 24 SWYC 36 SWYC 48 CY-BOCS ASRS Other N/A PSC-17 - DO NOT USE, record on PSC-17 tab
Name of other standardized, validated mental/behavioral health screening tool completed by the PCP other than PSC-17
PHQ GAD MDQ SCARED CRAFFT Vanderbilt SNAP IV CSSRS CMRS PRAPARE McLean Personality screener CATS DSM-V ASD Checklist AQ-10 R-MOAS SRS RBQ-3 MCHAT K-BIT EAT-26 SWYC 12 SWYC 24 SWYC 36 SWYC 48 CY-BOCS ASRS Other N/A PSC-17 - DO NOT USE, record on PSC-17 tab
Name of other standardized, validated mental/behavioral health screening tool completed by the PCP other than PSC-17
Anxiety Depressive Bipolar ADHD ASD Attachment Disruptive/impulse/conduct Eating/feeding OCD Trauma/stressor Schizo/psychotic Substance-alcohol Substance-marijuana Substance-nicotine Substance-opioids Substance-other Suicidality Other
Primary behavioral health diagnosis of patient or reason for PCP referral (e.g., a suspected diagnosis or mental/behavioral concern that prompted referral to BHH)
Anxiety Depressive Bipolar ADHD ASD Attachment Disruptive/impulse/conduct Eating/feeding OCD Trauma/stressor Schizo/psychotic Substance-alcohol Substance-marijuana Substance-nicotine Substance-opioids Substance-other Suicidality Other
Primary behavioral health diagnosis of patient or reason for PCP referral (e.g., a suspected diagnosis or mental/behavioral concern that prompted referral to BHH)
Anxiety Depressive Bipolar ADHD ASD Attachment Disruptive/impulse/conduct Eating/feeding OCD Trauma/stressor Schizo/psychotic Substance-alcohol Substance-marijuana Substance-nicotine Substance-opioids Substance-other Suicidality Other
Primary behavioral health diagnosis of patient or reason for PCP referral (e.g., a suspected diagnosis or mental/behavioral concern that prompted referral to BHH)
Anxiety Depressive Bipolar ADHD ASD Attachment Disruptive/impulse/conduct Eating/feeding OCD Trauma/stressor Schizo/psychotic Substance-alcohol Substance-marijuana Substance-nicotine Substance-opioids Substance-other Suicidality Other
Primary behavioral health diagnosis of patient or reason for PCP referral (e.g., a suspected diagnosis or mental/behavioral concern that prompted referral to BHH)
Diagnosis if not indicated in options
Please be sure to attach a Full/Complete Referral Packet to this request, which includes:
a completed/signed Release of Information
a completed/signed Consent & Authorization
a completed Mental Health Background Information form
a Clinical Note to indicate reason for referral
any psych evals or assessments
a scored PSC-17 and all completed screeners
a court order of guardianship (if applicable)
Please be sure to attach a copy of the following to this request:
Clinical Note to indicate reason for referral
Please be sure to attach a copy of the following to this request:
Any psych eval or assessment
Please be sure to attach a copy of the following to this request:
Court order of guardianship (if applicable)
Treatment by participating provider Referral to behavioral health or support services Both treatment by provider and referral to services
The BHH's recommendation for treatment of the patient's needs
Types of coordination activities performed
Level 1-Case Mgmt by Hub-No Med. Mgmt. (Add CM category/intervention) Level 2-Consultation w/Hub CAP (Telephone) Level 3-Evaluation by Hub CAP/PHD (Televideo) Level 4-Full Mgmt by Hub CAP (Co-mgmt, toggling between PCP+CAP)
Case Management/Care Coordination Notes
Date (0-11) Welcome Email Sent
Today M-D-Y
Date (12-21) Welcome Email Sent
Today M-D-Y