Clinician Referral Form
Patient Contact Info
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
DOB
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Insurance Carrier
Please Select
VIRGINIA MEDICAID
AETNA BETTER HEALTH (MEDICAID)
HEALTHKEEPERS PLUS (MEDICAID)
UHC COMMUNITY PLAN (MEDICAID)
OPTIMA/SENTARA (MEDICAID)
MOLINA (MEDICAID)
HUMANA MEDICARE HMO PLAN
ANTHEM/ HK / BCBS / BLUE CROSS PLANS
BLUE CROSS FEDERAL (prefix “R”)
SENTARA COMMERCIAL (NON MEDICAID)
AETNA (COMMERCIAL PLANS)
TRICARE
MEDICARE
UNITED HEALTHCARE (COMMERCIAL PLANS)
Member ID #
Insurance Card front
Insurance Card back
Referring Clinician Info
Provider Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referring Organization Name
Reason for Referral
Treatment-Resistant Depression
Major Depressive Disorder with Acute Suicidal Ideation
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BY SUBMITTING THIS FORM, I AM PROVIDING EXPRESS WRITTEN CONSENT FOR SEVA PSYCHIATRY TO CONTACT ME AT THE PHONE NUMBER I PROVIDED, INCLUDING THROUGH TEXT MESSAGES AND PHONE CALLS, REGARDING SERVICES, APPOINTMENTS, OR OTHER RELEVANT INFORMATION.
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