Patient Referral Form
This form is HIPAA-Compliant.
Your Practice Details
Name of Referring Provider
Referring Provider: Phone Number
Please enter a valid phone number.
Referring Provider: Email
example@example.com
Patient Details
Patient's Name
First Name
Last Name
Patient's Date of Birth
-
Month
-
Day
Year
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Patient's Phone Number
Please enter a valid phone number.
Patient's Email
example@example.com
Patient's Insurance
Aetna
Anthem Blue Cross
BCBS (out of state, not CA-based)
Beacon/Carelon/LA Care
Cigna/Evernorth
Medicare
Optum/United Healthcare
Tricare/Triwest
Other
Insurance Member ID#
Reason for Referral
OPTIONAL: We will contact your patient and match them with a therapist at Framework. Are there any factors you'd like us to consider when matching your patient to a therapist? Is there anything you'd like us to relay to the therapist beforehand?
OPTIONAL: Relevant Medical Reports
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OPTIONAL: Would you like to be contacted by someone from Framework's leadership to discuss opportunities for shared referrals? If so, please enter the email address for the appropriate contact within your practice, and we'll have someone reach out.
example@example.com
Thank you for your referral!
We will reach out to the patient within 1-2 business days.
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