Rapid Patient Referral 23'

To refer a patient to Bicycle, please fill out this secure form. We’ll use the patient's information to outreach them, and your information to share progress updates.
BH Jotform Type (engineering use only)
This determines what automation is triggered
Referral Source
Referral Medium
Referral Campaign
Referral Content
Referral Term
Referral Referrer
Patient Information
Name*

First NameLast Name
Patient Contact Email:*
Patient Phone Number: *
Please enter a valid phone number.
State*
Referrer Information
Referring Contact Name*
Referring Contact Email
example@example.com
Referring Medical Group or Referring Organization (if any)
CorrHealth Location*
Facility Name*
Notes (optional)
By submitting this form, I understand that Bicycle Health is an outpatient telemedicine-based opioid use disorder provider. Bicycle Health can treat most patients with opioid use disorder as long as they meet the following criteria:
- Over 18 years old
- Has a photo ID
- Has a phone
- Consents to telemedicine care
- Has a safe place to store medication
- Is not on Methadone, or on less than 40mgs of Methadone
Should be Empty:

Patient Information