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Forms

Provider Referral Form

Client Information - Adult

Notice Regarding Electronic Communication and HIPAA Compliance

All referral information submitted electronically via email must be sent from a protected, HIPAA-compliant server to ensure the privacy and security of patient health information. Please note that all email communications from SaSS KC are HIPAA-compliant. If you prefer to send referrals via fax, they may be sent securely to: (913) 601-8176

Client Information

Birthday
Month
Day
Year
Multi-line address

Physician Information

Referral Reason
Areas of concern or need
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