Premier Mental Health & Wellness Referral Form
Thank you for trusting us with your patients!
REFERRING PROVIDER NAME
So we can add you to our referral list and remain in contact.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
PATIENT CONTACT INFORMATION
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Sex
*
Male
Female
Email
*
example@example.com
Insurance Type
*
Please Select
Aetna
BCBS
ChampVA
Cigna/Evernorth
Medicare
UHC/UMR
Self Pay
Other
We accept most BCBS, Aetna, Cigna, Medicare, UHC/UMR plans
Insurance Information
Member ID
Group ID
Referring Provider's Comments
*
Reason for referral, special notes, etc.
Submit
Should be Empty: