Case Discussion Request

1

Thank you for considering Evolve Psychiatry for your behavior health case management needs. Please review and complete the following sections to get started!

Section 1: Patient Decision Guide

Section 2: Legal Agreement

Section 3: Payment

Section 4: Submission and Next Steps

2

What is the purpose of the case discussion?* This field is required.

Treatment progress update

Collaboration with therapist

Collaboration with medical provider

FMLA assessment

Disability claim assessment

Insurance claim denial/appeal assessment

Other

3

Have you requested the case discussion directly from your provider?* This field is required.We advise you to discuss these forms with your provider at your next visit. If you need them sooner than your next visit, please message the Patient Success Team via On Patient to alert your provider of the need and allow them to confirm that they are able to complete your request before processing this submission.

YES, I have already discussed the report with provider

NO, I have not discussed the report with provider yet

4

You will need to contact the Patient Success Team.

Please visit OnPatient to submit your request. Our office will contact you in 48 hours. You may close out of this window.

5

Patient Contact Name* This field is required.

First Name

Last Name

6

Patient Phone Number* This field is required.

Please enter a valid phone number.

7

Patient Contact Email* This field is required.Your submission confirmation will be directed to this email

example@example.com

8

Contact Information of 3rd PartyThis is who will be contacted to schedule the case discussion.

Name

Company Name/Title

Email

Phone Number

Country

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Case Discussion Expectations* This field is required.

10

Financial Responsibility* This field is required.

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Payment OptionsPlease select only ONE option

My Bag

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Standard DiscussionCall time: 15 minutes
$75.00Edit
Back
1
1
Quantity
Subtotal: $0.00
Extended DiscussionCall time: 30 minutes
$150.00Edit
Back
1
1
Quantity
Subtotal: $0.00

First Name

Last Name

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Signature* This field is required.

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After clicking the submit button, you will be automatically re-directed to our website to submit your Release Of Information. Please confirm the Contact Information of 3rd Party matches the information on the ROI. This will authorize us to schedule the 3rd party discussion call through either phone or email.