Railey & Associates Referral
2236 Capital Circle NE, Ste 203, Tallahassee, FL 32308
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Adult Forensics
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Patient Name
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E-mail
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Requested Service
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Psychological Evaluation
Psychological Evaluation - Stat (Attorney & MD Only)
Psychotherapy
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Name of Insurance
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Insurance ID Number
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Phone Number
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Relationship to insured
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Do you have any additional insurance plan(s)?
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Name of Insurance
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Insurance ID Number
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Phone Number
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Relationship to insured
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Child
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Summary of Case
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I certify that the information submitted in this application is true and correct to the best of my knowledge. I further understand that any false statements may result in denial or revocation of services provided.
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