TestTBI Referral Form

Patient / Client Name:*

DOB:*

Patient / Client Phone:*

Email:*

example@example.com

Attorney Name / Contact Info*

Date of Onset:*

Date

Is TBI suspected?

YES -> SCREEN & EVALUATE with a Full Battery of Testing

Difficulties:

Considerations:

Coordinate Care with:*

Clinic Name:*

Doctor:*

MD/DO/DC Signature:

Date of MD/DO/DC Signature:

Date

MD/DO/DC Phone:

MD/DO/DC Email:

example@example.com

Attorney Referral:*

Date of Referral:*

Date

Attorney Name:

Firm Phone:

Case Manager / Paralegal Name:

CM / Paralegal Email:

example@example.com

REFERRALS CAN ALSO BE EMAILED TO Referrals@TestTBI.com

CONFIDENTIAL HEALTH INFORMATION

Health Care Information is personal and sensitive information related to a person's healthcare. It is being faxed after appropriate authorization from the patient or under circumstances that do not require patient authorization. The recipient is obligated to maintain it in a safe, secure, and confidential manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law. Important Warning: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that dissemination, distribution, or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately and destroy the related message.

Health Information Management Department: Ph 770-434-8976

'The significant problems we face cannot be solved at the same level of thinking we were at when we created them.' - Albert Einstein