Professional Referral Form

Professional Referral Form
Thank you for referring a patient to us at Proven Pathways Psychotherapy.

Please complete the confidential and HIPAA-compliant form and we will contact the patient, typically within one business day to discuss their needs.
Insurances: We accept private pay, Aetna, Cigna, Medical Mutual, OhioHealthy, Medicare, Humana Medicare Advantage, and Devoted Health. We are certified out-of-network providers with TRICARE.

Access: Currently, we can generally place patients with a clinician within 1-3 weeks.

Fit: In referring, you do not need to be certain of fit. We will discuss the patient's clinical needs, preferences, and anticipated financial aspects of care given their insurance situation. If there is another practice that will be a better fit, we will make appropriate referrals.

Alternative method: if you would prefer to fax over a referral, you can fax us at 614-639-8223. Providers with COPC can use their internal referral system to refer.
Referring Provider Name (or organization, if no specific referring provider)
Referring Provider/Organization Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Provider/Organization Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Name

First NameLast Name
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email
example@example.com
Patient's Health Insurance Carrier, if known (e.g., Aetna, Cigna, etc.):
Reason for Referral
How would you like to be updated regarding this patient's care? We can discuss this preference with the patient and, if they consent, we can communicate the following with you as desired:

Other
Should be Empty:

Professional Referral Form

Thank you for referring a patient to us at Proven Pathways Psychotherapy.