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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

Please type the characters*

This helps us prevent spam, thank you.

This field should be left blank

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