Patient referral for Spravato treatment
Please send this referral form with copies of the most recent office notes, current PHQ-9 if available, demographics (to include ss# and email address) and insurance card(s). Fax to 888-836-0702
Patient Info
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Address
*
Street Address
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
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Policyholder Name
*
First Name
Last Name
Policyholder DOB
*
-
Month
-
Day
Year
Date
Medical History
Diagnosis
*
Medical Treatment / History
*
Medication History
*
Referring healthcare provider information
Name/Practice
*
Phone Number
*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Submit
Should be Empty: