Direct Connect Rapid Referral

FAX TO: St. Louis Chapter (serving eastern Missouri and western Illinois)
FAX #: 314-432-3824
 

 
Person making referral:
May we identify ourselves as the Alzheimer’s Association?
Monday - Friday between 8am - 4pm
I give permission to my healthcare or service provider to fax my name and contact information to the Alzheimer's Association. I understand that an Alzheimer's Association Helpline representative will contact me about support and educational opportunities. I understand this is a free service provided by the Alzheimer's Association. I understand that my name, contact information or health information listed below will not be disclosed or shared with any other entity unless authorization is obtained by me.
 

Signature – Patient or Representative

 
TO BE COMPLETED BY REFERRING PROVIDER
Reason for Referral: (Please check all that apply)


24/7 Helpline 800-272-3900 / www.alz.org