Referral Form

Referral Request
Thank you for choosing to refer your patient to Medens Health!

We are committed to providing excellent support for your patient through a seamless referral process, ensuring they are in good hands.

Please fill out the form below. Once we have your referral, a Patient Experience Liaison will contact your patient to start the onboarding process.
Patient Details
Name:*

First NameLast Name
What state does the patient reside in?*
Is the patient a minor:*

YesNo
Since you've indicated the patient is a minor:

1) Provide us the parent/guardians name in the referral section at the bottom of this form, and

2) Enter the parent/guardians phone number and email address below.
Mobile Number*
.
Email:*
example@example.com
Patient Insurance Information
Insurance:*
Mednes Health is In Network with these insurers only. If the patient's plan isn't listed, select 'Other'.
Date of Birth:*

MonthDayYear
Date
Clinical Information
Referral Type:*

Academic accomodation testingADHD testingAdolescent therapyAdult therapyASD testingBariatric pre-operative evaluationCouples therapyDislexia testingFamily therapyMedication managementPsychological testingSpinal Cord Stimulator (SCS) pre-operative evaluation
Please note: All medication management appointments for insurance based patients are currently full. At this time, we are only offering medication management appointments for self-pay.
Reason for Referral:*
Presenting Diagnosis (if known)
Do you have any documents to share? If so, upload your documents here. If you’d prefer to fax them, the referral fax is (844) 654-2900.

Cancelof
Submitter Information
Your Name:*
Practice/Organization Name:*
Your Email:*
example@example.com
Your Phone Number:*
.
Which of the following applies?*

Reach out to the patient directlyContact me to discuss first
Date*

MonthDayYear

AM/PM Option
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Referral Request