DocDX

Address: 11119 Rockville Pike, Suite 207, Rockville, MD 20852

Phone: (844) 443-6239 | Fax: (833) 464-4011

PATIENT INFORMATION

Full Name:

Date of Birth:

Phone:

Email:

Preferred Contact Method:

Phone Text Email

Insurance Type:

Medicaid Medicare Private Self-Pay

Language Preference (if other than English):

REFERRING PROVIDER INFORMATION

Provider/Clinic Name:

Referring Provider Name:

Phone:

Fax:

Email:

Contact for Follow-Up (if different):

REASON FOR REFERRAL

Opioid Use Disorder Continuity of care after discharge Initiation of MAT (Suboxone) Relapse prevention/support

Other

RELEVANT HISTORY (Optional but helpful)

Prior MAT use:

Yes No

If yes, which medication?

Last use of opioids (if known):

Co-occurring conditions or concerns:

ADDITIONAL NOTES / REQUESTS

Note

Please fax this form to (833) 464-4011 or email to info@docdx.com
You may also call us directly at 844-443-6239 with any questions.

We will contact the patient promptly and follow up with referring providers (with appropriate consent) to ensure
coordinated care.

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PATIENT INFORMATION

REFERRING PROVIDER INFORMATION

REASON FOR REFERRAL

RELEVANT HISTORY (Optional but helpful)

ADDITIONAL NOTES / REQUESTS

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