Referral Form

I understand that: • These records are owned by MercyCare • Information within these records will be shared with other staff within the MercyCare on and only when staff require the information to carry out their duties • I can ask to see records and receive a copy • Records are archived for a set period according to policy and procedure • I understand that all information obtained will be kept confidential. To the best of my knowledge, the information provided in this form is true and correct: