Public Health accepts referrals from professionals or individuals by online submission, phone, fax or mail. Email is accepted if sent by a secure, encrypted service to email@example.com.
Online submission via DocuSign 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.
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.