MSUD Appointment Request Form

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The MSDH Opioid & Substance Use Disorder (MSUD) Program is committed to improving access to evidence-based treatment and recovery support services for individuals affected by substance use disorders across Mississippi. This referral form is designed to facilitate timely and coordinated linkage to care, including medications for opioid use disorder (MOUD) and supportive resources.

Please complete this form as thoroughly and accurately as possible to ensure appropriate placement and follow-up. All referrals are reviewed by MSUD program staff, and individuals will be contacted to assess needs, determine the appropriate level of care, and connect them to available services within their region.

If you have questions or need assistance completing this form, please contact the MSUD Program at msud@msdh.ms.gov.

Please note that the MSDH MSUD Program is currently limited to accepting new referrals from residential treatment facilities and healthcare providers.

Time started

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M-D-Y H:M

Which one best describes you?

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I am a provider requesting services for a patient

I am completing this for a client being discharged from a residential treatment facility or prison

MSDH MSUD team internal use only

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Patient's first name:

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Patient's last name:

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Patient's date of birth:

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M-D-Y

Patient's Age (Years):

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Last 4 digits of Social Security Number:

Patient's Email:

Patient's Phone Number:

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Patient's Physical Address:

City/Town:

State:

Zip/Postal Code:

When is the best time of day to contact the patient?

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Anytime of day

Morning

Lunch

Afternoon

Other:

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Patient's Gender

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Male

Female

Non-binary

Other

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Patient's Gender

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Male

Female

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Is the patient pregnant or breast feeding?

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Yes

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With which racial group(s) does the patient identify?

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White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other:

Is the patient of Hispanic, Latino, or of Spanish origin?

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Yes

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Does the patient have health insurance?

(The patient does not have to have health insurance to request services.)

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Yes

I don't know

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Please enter the following information from your card. If you prefer, you may upload a picture of the front of your medical insurance card(s).

Note: Not all medical insurance cards will have all of the following information. Leave the field blank if the information is not on your card.

Insurance Provider (Blue Cross, Medicaid, etc.):

Cardholder's Name:

Policy/ID Number:

Group:

Relationship to Cardholder:

Upload file

Please upload a photo of your valid government-issued photo ID here (optional).

Upload file

What is your substance of choice?

Approximately how long have you been using this substance?

What is the patient's substance of choice?

Approximately how long has the patient been using this substance?

Friend/Family Member's Name:

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Relationship to Patient:

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Friend/Family Member's Phone Number:

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Name of referring provider:

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Name of referring provider's practice:

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Address of referring provider's practice:

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Referring provider's office number:

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Name of Residential Treatment Facility or Prison:

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In case we need additional information, who is the best person to contact at the treatment facility or prison? Please enter their name and title.

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Residential treatment facility or prison phone number where point of contact can be reached:

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Client's Projected Discharge/Release Date:

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M-D-Y

Please upload the client's discharge plan including their medication list here.

Upload file

Please upload the MSDH Patient Acknowledgement Form or Release of Information Form here.

Upload file

Name of Organization or Court:

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Point of Contact at Organization or Court:

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Point of contact's phone number:

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Will the patient need transportation to the county health department for services?

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Yes

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Please select the county health department location that is most convenient for the patient.

Please note that each county health department has different operating hours, so it is not guaranteed that the patient will be able to receive services at the preferred county health department.

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Appointment Date (MSDH Internal Use Only):

M-D-Y

CHD Region

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Thank you for filling out this form.

Once you hit submit, your request will be sent to our scheduling team.

You can expect our team to contact the patient within 5 business days. The patient will receive a call from one of our staff members to schedule an appointment. If you have not heard from our team within 5 business days or have any questions, please feel free to email msud@msdh.ms.gov.

You will be required to present a valid government-issued photo ID at your appointment.

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