MyEzMed Virtual Mental Health Services Physician Referral Request

MyEzMed Virtual Mental Health Services

Referral Request for Original Medicare Patients
Our team will collaborate with your office to support your patient care. We will follow up directly with the patient to schedule an initial evaluation. After the evaluation, we’ll share a clinical summary with your office, including recommended next steps.
Referring Physician Information
Name

First NameLast Name
Practice Name
Phone Number
Format: (000) 000-0000.
FAX Number
Format: (000) 000-0000.
Email
example@example.com
Patient Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Primary Mental Health Condition
Date of Last Patient Visit

MonthDayYear
Date
Please Upload Patient Information (i.e., insurance card, medication list, clinical notes)

Cancelof
Additional Information? (optional)
Confidentiality Notice: This form may contain protected health information (PHI) and is intended only for the provider named above. If you are not the intended recipient, please notify us immediately and destroy all copies.
www.myezmed.com Contact: (888) 305-8730 FAX: (424) 254-3046
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MyEzMed Virtual Mental Health Services