Behavioral Health Referral

Behavioral Health Referral

This form is HIPAA compliant and uses encryption
Patient Information
Referral Date *

Month Day Year
Date
This person is a current patient at our practice and is in need of a behavioral health assessment and/or treatment from your agency:
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date

Patient Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Legal Guardian (if patient under 18yo)

First Name Last Name
Patient/Guardian Phone Number *

Area Code Phone Number
Payer Source *

Medicaid Self-Pay Anthem BCBS
Provider Information
Provider Name *

First Name Last Name
License Type *

MD DO PA NP
NPI Number
Practice Name *

Practice Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Practice Phone *

Area Code Phone Number
Practice Fax *

Area Code Phone Number
Practice Email
example@example.com
Specific Concerns, Diagnoses, Requests, and/or Recommendations *
If you have additional documentation, upload it here

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Provider Signature *

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