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Home
About
- COVID-19 Update
- Videos
Services
- Suboxone® Treatment
Referring Provider Form
Contact

Referring Provider Form

Referring Provider FormDaniel Merkl2022-02-16T17:04:31+00:00

In addition to completing this form, please upload files or fax all relevant medical records to (866) 702-0880.

Patient Name*

First

Last

Date of Birth*

Phone Number(s)*

Insurance Provider*

Policy Number*

Effective Date*

Referral Type*

Evaluation

Opiate or Other Dependence

Description*

Comments

Location*

Please include available patient demographics and clinic notes

Referring Provider*

(Include NPI, if known)

Contact Person*

Phone*

Fax*

EHR Direct Messaging Address*

Upload

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Please type the characters*

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