REFERRAL for Outpatient Therapy

REFERRAL FOR OUTPATIENT THERAPY
ReeVision Network LLC.

Norfolk (6325 North Center Drive Suite 230, Norfolk VA 23502)
Date of Referral

MonthDayYear
Date
Referred By:*
If other for above question, please provide detail below:
Location preference:*
Client's First and Last Name*
Client's Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security # (for children under 18, please input guardians social)*
Address*
Responsible Party Name and Number*
Emergency Contact Name and Number*
Do you have Tricare?*

YesNo
Which do you have:

Tricare SelectTricare PrimeOther
Please Review this Memo
If a client holds two insurance policies and you fail to provide the required coverage or documentation, you WILL be held financially responsible.
Insurance Provider (Primary)*
Insurance ID# (Primary)*
Insurance phone # (Primary)
Insurance Group # (Primary)
Insurance Holder & DOB*
Do you have secondary insurance?*

YesNo
Insurance ID# (Secondary)*
Insurance ID# (Secondary)*
Insurance phone # (Secondary)
Insurance Holder & DOB (If same as primary, you may skip)
Brief Description of Reason for Referral*
Does client have any other providers? If so, list name and phone numbers
Form can be submitted electronically and or faxed to 757-210-3868 or emailed to intake@reevisionnetworkllc.com.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance card upload (photo or document)*

Cancelof
Secondary Insurance card upload (photo or document)*

Cancelof
Photo ID ( for minors parent please upload your ID)*

Cancelof
Should be Empty:

REFERRAL FOR OUTPATIENT THERAPY

If a client holds two insurance policies and you fail to provide the required coverage or documentation, you WILL be held financially responsible.