How to Download and Use Our Interactive Referral Form

Step 1: Download the Form and SAVE to Your Computer

Step 2: Open the Form

Open the downloaded form using Adobe Acrobat Reader (available for free on ).
To protect patient privacy under HIPAA, ensure the form is opened only on a secure, password‑protected device.
Use an updated version of Adobe Acrobat Reader to ensure full functionality and secure handling of electronic protected health information (ePHI).

Step 3: Fill Out the Form

Enter patient information only within the designated fillable fields.
Use drop-down menus, checkboxes, or radio buttons where indicated. Double-check all entries for accuracy before saving.

HIPAA Reminder:
Complete the form in a private, secure location where patient information cannot be viewed or overheard by unauthorized individuals.

Step 4: Save Your Completed Form

Click File > Save As to keep a copy on your device.
Choose a recognizable file name and a location for easy access.
Save the file only to a secure, encrypted, password‑protected location in compliance with HIPAA data security standards.

Step 5: Submit the Form

Choose one of the approved HIPAA‑compliant submission methods:

Secure Online Submission

Click SUBMIT FORM if enabled, or send the completed form to info@adlertherapygroup.com using a secure email system approved for transmitting protected health information.

If your clinic’s standard email system is not encrypted, contact Adler Therapy Group for a secure alternative (e.g., secure portal, encrypted email exchange).

Printed Submission

If preferred, print the completed form and deliver it:

At the patient’s appointment, or
To the Adler Therapy Group office using secure internal transport procedures.

Printed forms should be handled according to HIPAA physical safeguards—do not leave them unattended.

Clear Form

To remove all entered data and reuse the form, click CLEAR FORM.

Before clearing, ensure any protected information has been securely saved or submitted per HIPAA guidelines.