Maine Single Assessment Referral Request

Terms of Use for Submitting a Single Assessment Referral Form*

The participant must read all of the terms below to fill out the online referral form in its entirety.

1. Acentra Health follows all federal regulations regarding confidentiality and privacy. Protected Health Information (PHI) is being collected and handled in accordance with the Health Insurance Portability and Accountability ACT (HIPAA) and relevant federal and state privacy laws. All information you provide will be stored and transmitted via secure, encrypted systems, with access restricted to authorized team members only.
2. Member’s information will be used solely for referral purposes and will not be utilized for any unrelated purpose without the member’s explicit consent.
3. This form is not intended to replace emergency care. If you or the person you are referring is experiencing a crisis or a medical emergency, please call 911, 988, or go to your nearest emergency department immediately
4. An Acentra Health representative will contact the Guardian within one business day (excluding weekends and holidays) to either:
   1. Schedule a single assessment, or
   2. Assist in connecting the referent to other treatment resources if an assessment is not deemed necessary.
5. By proceeding, you affirm that you understand and consent to these terms.