Public Health Nursing Referral

Sections

Public Health accepts referrals from professionals or individuals by online submission, phone, fax or mail.

Online submission via DocuSign (preferred)
This version is recommended for senders without secure email. DocuSign is secure and fully HIPAA compliant. It also allows you to easily save a copy of the referral in your system.
Nurse referral form (Fillable PDF)
Email is accepted if sent by a secure, encrypted service to publichealth@bloomingtonmn.gov.

Fill out the DocuSign signer information page with your name and email and click BEGIN SIGNING.
Check “I agree…” and click CONTINUE.
Fill out the DocuSign form with referral information.
Note: there is no “signature” needed, filling out the form is considered signing.
Red outlined fields are required, but you may enter other explanatory text if you don’t have the exact information requested.
You may download or print a copy for your records.
Click FINISH to submit the referral.
Close DocuSign.

Include detailed information about the reason for the nurse visit. A more complete form will help us better meet an individual’s needs.
Email or fax a discharge summary or other relevant medical information as appropriate, along with the completed referral form. (Bloomington Public Health does not have access to Epic or any other external electronic medical records.)
For parent/baby (postpartum/newborn) referrals, please put parent at the top of the form and put baby under other family members. Include baby’s date of birth and relationship (son, daughter) to the parent.

Questions? Contact Public Health at 952-563-8900 or publichealth@BloomingtonMN.gov.

Thank you for your help in protecting the health of our community.