Amity Medical Group - Behavioral Health Services Referral Form

Behavioral Health Services Referral Form

Amity Medical Group
Date of Referral*

MonthDayYear
Date
Preferred Appointment Type

In-PersonTelehealthEither
Referral Source

Provider Information
Referring Provider/Agency Name*
Contact Person*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this referral urgent?*

YesNo
If yes, please explain:
Client Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Preferred Language*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/ Guardian (if applicable)

First NameLast Name
Relationship to Client
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Insurance Provider*
Member ID*
Group Number*
Policyholder Name (if different)

First NameLast Name
Insurance Type*

MedicaidMedicarePrivateUninsured

Client/Guardian Consent
I authorize the release of the information contained in this referral to the receiving behavioral health provider for the purpose of coordinating care and services.
Client/Guardian Signature*
Client/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Behavioral Health Services Referral Form