Refer a Patient

    To refer a patient to Affirmation Health, please fill out this secure form. We’ll use the patient's information to outreach them, and your information to share progress updates.

    Patient Information

    State:

    Referrer Information

    Referring Medical Group or Referring Organization (if any)

    Notes (optional)

    By submitting this form, I understand that Affirmation Health is an outpatient telemedicine-based (health-care provider). Affirmation Health can treat most patients with opioid use disorder as long as they meet the following criteria:

    -Over 18 years old

    -Has a photo ID

    -Has a smartphone

    -Consents to telemedicine care

    -Has a safe place to store medication