You may call the administrative office directly at 602-788-1116 to request a referral form, or you may click below to download, print and complete the form.

Fax or E-mail

Download, Print and Complete our simple Referral Form, and Release of Information forms. Once completed, you may either fax to 602-788-1119 OR scan and send via email to

Maricopa-info@azbcinc.com

with subject line: Referral Form. (Please note our forms are in .pdf format and will require a pdf viewer. If the computer you are accessing this form with does not have the software, you can download Adobe Acrobat Reader, for free, here.


Referrals