HUB to Spoke (OBOT) Referral Form Today’s Date: Spoke Provider Information HUB Referring Contact Physician: Number: Spoke Physician: Contact Number: Spoke Nurse or Contact Clinician Name: Number: Patient Information Patient Name: DOB: Patient Contact Gender Male Female Number: ROI Completed Yes No Records Yes No Requested: Description of Request: Dosing Information Current Dose: Number of Take Homes: Length of time on Take Home Medication: Dosing History: Treatment Information Treatment Needs Questionnaire score: Behavioral Health Questionnaire Score Spoke (OBOT) Stability: Current Prescriptions: Current Use: UA Screening Results for the Opiates Cocaine Alcohol Amphetamine Benzo’s last 3 months: Pos Pos Pos Pos Pos
HUB to Spoke (OBOT) Referral Form Today’s Date: Spoke Provider Information HUB Referring Physician: Contact Number: Spoke Physician: Contact Number: Spoke Nurse or Clinician Name: Contact Number: Patient Information Patient Name: DOB: Patient Contact Number: Gender Male Female ROI Completed Yes No Records Requested: Yes No Description of Request: Dosing Information Current Dose: Number of Take Homes: Length of time on Take Home Medication: Dosing History: Treatment Information Treatment Needs Questionnaire score: Behavioral Health Questionnaire Score Spoke (OBOT) Stability: Current Prescriptions: Current Use: UA Screening Results for the last 3 months: Opiates Pos Cocaine Pos Benzo’s Pos Alcohol Pos Amphetamine Pos
HUB%20to%20Spoke%20Referral%20Form.docx