PROVIDER assistance
This form is for medical/behavioral health providers/support staff.
Name
*
First Name
Last Name
Email
*
example@example.com
What type of provider are you?
*
Medical
Behavioral Health
Occupational Therapist
Physical Therapist
Social Worker
Other
Where do your practice (City/State)?
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I am requesting help with the following;
*
Referral for a PANDAS/PANS suspected patient
Education
Testing/Treatment for PANDAS/PANS patient
IVIG support
IVIG denial support
Crisis management
Brochure/Flyer request to have in office
Other
If you have a case of suspected PANDAS/PANS, are you willing to utilize the established diagnostic and treatment guidelines to assist this patient if it is within your scope to do so?
*
Yes
Maybe
No
Other
Add any additional information you would like us to know here:
Submit
Should be Empty: