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Referring A Patient
Screening Checklist
Clinician Articles
Referring a Patient Form (For Your Patient)
Enter pertinent information to facilitate the referral.
Patient Name
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Patient DOB
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Age
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Gender
Male
Female
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Address
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City
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State
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Zip
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Best phone number to reach patient
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Alternate Phone
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If the patient is a minor (less than 18 years old), the following is requested
Legal guardian’s name
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Legal guardian’s address
Same
Different
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Address
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City
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State
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Zip
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Legal guardian’s phone number
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Relationship to Patient
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Name of referring provider
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Address of referring provider
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Phone
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Fax
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Reason For Referral
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Billing Note
Treatment fees in full are the responsibility of the patient or assigned payor. Although we do not accept payments from insurance, we will provide necessary forms to your patient so that he/she may submit directly to their insurance for reimbursement.
Fill out this security field before submitting
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