COE Referral Form | Tower Health

How to Make a Referral

Call the Center of Excellence directly at 484-628-4060 or 484-628-5790 (Spanish: 484-628-4984), or complete the referral form below. You can do this for yourself or someone else. Upon receiving a referral, a member of the Center of Excellence Care Management team will contact you or the person you've identified within 24 hours to discuss recovery, how the Center of Excellence can help, and what the next steps are.

Required fields are marked with *

First Name

Last Name

Relationship to Patient

Patient Primary Phone Number

Patient Secondary Phone Number

Gender

Male

Female

Date of Birth

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Do you have an Opiate Use Disorder?

Yes

Reason for Referral

Referring Entity/Person

Complete this section only if you are making this referral on behalf of someone else.

Referring Entity/Person

Referring Entity/Person Phone Number

Referring Entity/Person Email