Patient Referral Form

Patient Referral Form

Phone: (281) 815-5782 Fax: (346) 209-2029 admin@cuspbehavioral.com
This form must be completed and submitted to Cusp Behavioral Health by the office of a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team. If you are a parent/guardian or other provider seeking to access ABA services or refer a client to Cusp Behavioral Health, please contact us at (281) 815-5782 or visit our website at www.cuspbehavioral.com.
- Patient's Name
  
  First NameLast Name
- Patient's Date of Birth
  
  MonthDayYear
  Date
- Parent/Guardian Name
  
  First NameLast Name
- Parent/Guardian Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Parent/Guardian Email
  example@example.com
- Provider's Name
- Provider's NPI Number
- Practice Name
- Practice Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Practice Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Practice Fax Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Practice Email
  example@example.com
- Contact Name
  
  First NameLast Name
- Client Diagnosis Code(s):
- Date of Diagnosis
  
  MonthDayYear
  Date
- Level 1: Requiring SupportLevel 2: Requiring Substantial SupportLevel 3: Requiring Very Substantial Support
- Diagnostic Report
  
  Cancelof
- To request authorization for an initial ABA assessment and ongoing treatment, some insurance providers require diagnosing clinicians to sign a prior authorization form which indicates agreement with the requested treatment hours. This form will be faxed to your office once eligibility has been determined and all required documents have been received. The prior authorization form must be returned as soon as possible. If you have any questions, please contact our office at (281) 815-5782.
  
  Thank you for partnering with Cusp Behavioral Health!
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