Retail Clinic to HIV Treatment Center Referral Form

Streamline HIV Care Referrals with Paperform

When a retail clinic identifies a patient with a positive HIV test result, swift and coordinated referral to specialized care can make all the difference in patient outcomes. This Retail Clinic to HIV Treatment Center Referral Form template is designed specifically for healthcare providers who need to transfer patients efficiently while ensuring all critical medical information is captured and communicated.

Built for Healthcare Coordination

This form template addresses the unique workflow challenges facing retail clinics, urgent care centers, and community health providers when referring patients to designated HIV treatment centers. It captures essential baseline laboratory data, documents antiretroviral therapy (ART) readiness, and facilitates seamless care coordination between referring and receiving providers.

The form guides healthcare staff through documenting:

• Complete patient demographics and contact information
• Referring clinic details and provider information
• HIV test results and confirmation data
• Baseline laboratory requirements (CD4 count, viral load, STI screening)
• Existing medical conditions and current medications
• Insurance and financial assistance information
• Urgency assessment and patient needs

Why Paperform for Medical Referrals?

Paperform's flexible form builder lets healthcare administrators create professional, HIPAA-awareness-focused forms that match your clinic's branding and workflow. While Paperform itself is not HIPAA compliant and should not be used to collect PHI without proper safeguards, it can be integrated into compliant workflows for non-PHI coordination tasks or used in conjunction with your existing secure systems.

Enhance your referral workflow with Stepper: Connect this form to Stepper to automatically route referrals to the appropriate HIV treatment center, send confirmation emails to both referring and receiving providers, update your patient management system, and trigger follow-up reminders to ensure patients complete their first appointment. Stepper's AI-native automation can help you maintain compliance documentation and reduce the manual work of care coordination.

Secure signatures with Papersign: Use Papersign to obtain patient consent for information sharing, treatment authorization, and program enrollment directly after the referral form is submitted, keeping all documentation linked and auditable.

This template is ideal for retail clinics, urgent care centers, community health organizations, federally qualified health centers (FQHCs), public health departments, and any healthcare provider involved in HIV care coordination and specialist referrals.