Outpatient Referral Submission Form
Your Name
*
Your Email
*
example@example.com
Your Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Adolescent
*
Adolescent Name
*
First Name
Last Name
Adolescent Date of Birth
*
/
Month
/
Day
Year
Adolescent Age
*
Insurance Information
PLEASE NOTE
There is
NO Coverage
for Outpatient Services with Insurances listed below :
Aetna Better Health MCD
Aetna Better Health/Foster
Driscoll MCD
First Care MCD
Medicare Novitas (
EXCLUDES
Part A
ONLY)
TMHP
Insurance Coverage:
*
Please Select
Aetna Commercial
Aetna Medicare
BCBS
Carrelon Commercial
Christus Health Plan
Cigna/Evernorth
Compsych
Community First MCD (Under 21 Only)
Community First HMO
Magellan
Medicare Novitas (PHP ONLY)
Molina Medicaid
Molina Medicare
Humana Commercial
Humana Tricare
Optum/Oscar
Superior Medicaid
Superior Medicare
Ambetter (IOP ONLY)
UBH
UMR
Wellcare Medicare
Wellpoint MCD
Wellpoint MCR
Additional Information
*
Submit
Should be Empty: