Contact Us — Kingdom Elements AMDC

New Participant Referral Form (click here)

Thank you for your interest in Kingdom Elements AMDC! Please complete the forms and application information to start your enrollment process. Hospital Referrals can be submitted via the electronic form below or by downloading this form.

Are you a new participant? Click here to apply

Clinical Referral Form

A Kingdom Elements staff member will be in touch with you soon. Please complete and carefully read the referral form below. We are here to help! If you should have any questions or immediate needs, please contact us.

Office#: 443- 793-8485 or email us

Fax#: 443-773-0700

PATIENT REFERRAL INFORMATION

Admission Requirements:

Please check each requirement to ensure that the Admission paperwork will be successfully submitted.

3871B submitted in the Telligen System (Required by Hospital only)

Signed Physician's Order for Admission to a Medical Adult Daycare

Initial Health Order

MOLST Form

Voluntary Transfer Form (if already active at another day program)

Type of Insurance/Payment

Patient Name

First Name

Last Name

Patient Date of Birth

Patient Phone #

(###)

###

####

Patient Medical Assistance #

Kingdom Elements Service Requested:

Adult Medical Daycare (Mon-Sat 9am-2pm)

Housing Placement

Psychiatric Rehabilitation Program

Hospital Referring From:

Hospital Referral Phone

(###)

###

####

Hospital Contact Email

Call us today

Email Us

Have questions? Need more support completing your paperwork? Our staff at Kingdom Elements AMDC is waiting for our call. We’re here for you.

Clinical Referral Form

Call us today

(443) 793-8485

Hours

connect

Kingdom Elements AMDC

Contact

our services housing placement contact