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

Sarah Miller, COA, OSA: Referral Services Supervisor- 207.810.3876

Referral Form
Complete and submit this form with every patient referral. If you plan to co-manage the patient with an EMG provider, indicate this on the form and include the completed Co-Management Form.


Co-Management Form
Complete this form only if you are requesting co-management. It must be signed by both the referring provider and the patient and submitted with the Referral Form.