Please fax all forms to the Care Coordination Team

Fax: 207-810-3800

Do you have questions? Call 207.828.2020 ext. 4000 

Jean Proctor, RN, CRNO: Care Coordination Nurse

Adrienne Cady, COA, OSA: Care Coordination Technician

Referral Form

Please download and send this form with any referral. If you intend to co-manage this patient with EMG providers, please indicate on this form

Referral FormDownload
Co-Management Form

If you have indicated you wish to co-manage with EMG providers on the referral form, please download, have referring provider and patient sign, and send in with the referral forms

Co-Management FormDownload