PSYCHOLOGICAL TESTING REFERRAL FORM

PSYCHOLOGICAL TESTING PROVIDER REFERRAL FORM

Stephanie Richardson, Psy.D, LP, LPC
Patient Full Name*
Date of Birth*

MonthDayYear
Date
Age*
Gender*
Phone Number*
Please enter a valid phone number.
Gaurdian if Applicable
Relationship to Patient (if applicable)
Scheduling Email*
example@example.com
Referring Provider Name*
Signature*

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NPI*
Date*

MonthDayYear
Date
Clinic Name
Provider Phone Number*
Please enter a valid phone number.
Provider FAX Number*
Please enter a valid phone number.
Briefly Explain Purpose For Referral*
Current and/or Prior Treatments*

PsychotherapyMedicationsTMSECTOther
PRESENTING CONCERNS:

Please check any that apply
AnxietyDepressed moodInattentionSelf-harm behaviorsExcessive worryMood dysregulationPoor FocusIrritabilityDistractibilityObsessive/Compulsive SymptomsSubstance UseInsomniaCommunication skillsInterpersonal issuesHyperactivityFatigueMemory/ForgetfulImpulsivityPsychosisSuboptimal response to treatmentsOther
REASON FOR REFERRAL: (Please check all that apply)*

Provide Diagnostic ClarificationAssist with Treatment PlanningAssess Cognitive Functioning
ICD-10 DIAGNOSES Codes For Prior Authorization*
Does the patient need any accomodations?*

NoYes:
Yes: (details)
Patient is aware of referral and provides consent to be contacted by Willow Medical*

YesNo
PATIENT INSURANCE INFORMATION: We do not accept Medicaid/Medicare/Workman's Compensation
Primary Insurance Carrier*
Subscribers Name*
Policy Number/Member ID*
Group Number*
Patients Relationship to Subscriber*
Subscriber Date of Birth*

MonthDayYear
Date
Last 4 of Subscriber SS*
Secondary Insurance Carrier
Subscribers Name
Policy Number/Member ID
Group Number
Patient’s relationship to subscriber
Subscriber’s Date of Birth

MonthDayYear
Date
Last 4 of Subscriber SS
UPLOAD form using link via website or FAX to 907-222-0754.

Please include relevant medical records: intake evaluations, current diagnoses, most recent appointment notes, current medications, and a summary of active medical problems and a Release of information. (Patient can also sign the ROI at our office or in their Patient Registration Packet submission).

We appreciate your referrals!

920 E 72nd Avenue Anchorage, Alaska 99518 Phone: 907.222.0753 Fax: 907.222.0754
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PSYCHOLOGICAL TESTING PROVIDER REFERRAL FORM

PRESENTING CONCERNS: