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Social Determinants of Health Provider Referral FormUse this form to refer a member to Peach State Health Plan for outreach from the Social Determinants of Health Department.

Please check the reason for the referral: required *
Non-Adherence To Treatment Plan:
Social Determinants:
ED Diversion (three or more ED visits within 90 days)
Recent Inpatient
Identified Health Care Gaps
Reason Type:

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