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Referral Form

We prefer to receive clinical referrals
as a fax from Electronic Health Records, but feel free to refer yourself or someone else using this form.
Please note that this form is not HIPPA compliant, so if you want to be assured privacy, please make your referral by calling (505) 591-4200.

Referral Form

Please fill out the following form and submit to us.

Reasons for Referral (check all that apply) Required

Thanks for submitting this referral. We will contact the person referred now.

Tel: 505-591-4200

Fax: (844) 605-1807

Email:  director@bridgetohealthnm.org

Mailing Address: 33A Thanpi Tside Poe, Santa Fe, NM 87506

Physical Address: 628 Riverside Drive, Ste C, Espanola, NM 87532

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© 2022 by Bridge to Health NM

Thanks!

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