Please fill out all required fields for the following referral form. If you have any questions, contact MVNA Intake (phone:612-617-4700 fax:612-331-5348)
Note: If the client lives in Bloomington, Richfield or Edina, please refer to the Bloomington Public Health website, call 952-563-8900, fax 952-563-8997, or email firstname.lastname@example.org.
Please attach a copy of patient’s discharge or clinic summary with orders. (upload up to 3 documents)