Primary Care to Community Health Worker Referral Form

Streamline Patient Referrals to Community Health Workers with Paperform

Community health workers (CHWs) play a vital role in bridging the gap between clinical care and social support, yet many primary care practices struggle with inefficient referral processes that rely on paper forms, faxes, or scattered email chains. This Primary Care to Community Health Worker Referral Form template transforms that workflow into a streamlined, digital experience that captures social determinants of health, identifies navigation needs, and connects patients to essential community resources—all in one place.

Why Healthcare Providers Choose Paperform for CHW Referrals

Primary care physicians, care coordinators, nurses, and social workers need a referral system that works as fast as they do. Paperform's doc-style editor lets you customize this template to match your clinic's protocols, add your branding, and embed it directly into your EMR portal or staff dashboard. Unlike rigid healthcare forms that feel clinical and impersonal, Paperform gives you the flexibility to create a warm, welcoming referral experience that respects patient dignity while capturing the critical information CHWs need to provide effective support.

This template includes comprehensive social determinants of health screening covering housing stability, food security, transportation access, financial strain, and social isolation. Conditional logic ensures that only relevant follow-up questions appear based on initial responses, creating a shorter, more respectful intake process that doesn't overwhelm referring providers or patients.

Built for Modern Healthcare Workflows

The referral form integrates seamlessly with the tools healthcare teams already use. Send referrals directly to your CHW program coordinators via email notifications, log submissions in Google Sheets or Airtable for case tracking, sync with your CRM or case management system through native integrations, or use Stepper to trigger multi-step workflows that automatically assign cases, send welcome messages to patients, and schedule follow-up check-ins.

For practices serving diverse populations, this form supports multilingual patients through custom translations and includes fields for preferred language, need for interpretation services, and cultural health mediation requests. The template captures immigration status concerns, health literacy needs, and trust barriers that might affect care navigation—details that are essential for CHWs but often missed in standard referrals.

From Referral to Resource Connection

The form goes beyond basic screening to capture specific navigation support needs: help scheduling appointments, understanding insurance benefits, accessing transportation, filling prescriptions, or connecting to behavioral health services. It includes sections for identifying relevant community resources (food banks, housing assistance, utility support, legal aid) and gathers consent for CHWs to coordinate directly with these organizations on the patient's behalf.

With Papersign, you can collect required consent forms and HIPAA authorizations right in the referral workflow, eliminating the need for separate paperwork and ensuring CHWs have proper documentation before beginning outreach. This keeps your program compliant while reducing administrative burden on busy clinical staff.

Perfect for Primary Care, FQHCs, and Health Systems

This template is designed for:

• Primary care practices implementing CHW programs or referring to community-based CHW organizations
• Federally Qualified Health Centers (FQHCs) with integrated CHW teams addressing social determinants
• Health systems and ACOs coordinating care for high-risk patients through CHW navigation
• Community health organizations receiving referrals from multiple clinical partners
• Care coordination teams in Medicaid managed care or value-based care programs

Paperform is SOC 2 Type II compliant and offers robust security features that meet healthcare data protection standards (note: Paperform is not HIPAA compliant, so ensure your use case aligns with appropriate data handling protocols). You can control who sees what with roles and permissions, track submission history, and export data for quality improvement reporting.

Automation That Supports Better Outcomes

Use Stepper to build intelligent workflows around each referral: automatically triage urgent cases to CHWs within 24 hours, send patient welcome packets in their preferred language, schedule initial outreach calls, and trigger follow-up reminders at 30, 60, and 90 days to track progress on social needs. This automation ensures no referral falls through the cracks and gives your CHW program the structure it needs to demonstrate impact.

With AI Insights, you can analyze referral patterns to identify the most common social determinants affecting your patient population, track which resources are most frequently needed, and generate reports that help you advocate for funding or partnerships that address gaps in your community's safety net.

Get Started in Minutes

Whether you're launching a new CHW program or modernizing an existing referral process, this Paperform template gives you everything you need to connect patients to comprehensive support services. Customize the screening questions to match evidence-based tools like PRAPARE or your state's Medicaid requirements, add your program's logo and contact information, and start receiving referrals that help CHWs make a real difference in patients' lives.

Trusted by healthcare providers, community health organizations, and care coordination teams nationwide, Paperform makes it easy to build the referral infrastructure that supports whole-person care and addresses the social factors that drive health outcomes.