Referring Health Providers

The COACH Program Referral Form

Complete the form below to refer your patient for The COACH Program.

Referrer details

* All fields are required unless marked (optional)

Referring provider name

Referring provider specialty (optional)

Email address

Phone number

Comments (optional)

Member details

* All fields are required unless marked (optional)

First name

Last name

HBF member number (optional)

The 8 digit number on the front of a member's HBF card.

Phone number

Referral authorisation

Member has consented to referral for The COACH Program

Member has consented to their personal information being shared with the HBF health programs team for the purpose of making a referral to The COACH Program. HBF will use this information to contact the member, confirm eligibility and schedule an appointment.

I have read and agree to the Privacy Policy and Providers / Health Practitioners Collection Statement

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.