EAST REGION REFERRAL PACKET
Individuals served in Cayuga, Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne and Yates counties should use the East Region Referral Form.
All individuals will need to read the HIPAA Notice of Privacy Practices and sign an Authorization for Release of PHI and Acknowledgement of Notices and Privacy Practices. Please save these items and open them using Adobe Reader or a similar product. Continue scrolling for additional information.
Please watch the video provided for more information on consent form completion.
Once the forms are completed and signed, they can be emailed directly to firstname.lastname@example.org or faxed to (716) 671-2175. They can also be sent, along with a self-addressed stamped envelope to Person Centered Services, Intake Dept., 1090A Union Road, Suite 260, W. Seneca, NY 14224.
Upon receipt of the information requested an Intake Specialist will reach out and begin assisting you with the intake and enrollment process.
Please fill out and submit the following forms:
You can reference the sample examples below for filling out acknowledgments and authorizations: