BlueCross BlueShield of Texas

Thank you for referring one of your members to Carson’s Village. We are honored to extend your services through Carson’s Village. While we agree confidentiality is a high priority, please provide some generic information below so we can track the success of this pilot program.

Name of BCBS Representative*
First Last
Representative's Phone Number*
Representative's Email*
Date*
MM slash DD slash YYYY

Please provide the date you referred Carson's Village.
Time*

: Hours

Minutes

AM/PM

Please provide the time you referred Carson's Village.
Did you recommend the Carson's Village website or the phone number?*
What was the scope of service needed for the family you referred?*
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