SMC External Referral Form

SPECIALTY MEDICATION CLINIC

REFERRAL FORM
IF THE PATIENT IS EXPERIENCING A MEDICAL OR PSYCHIATRIC EMERGENCY, DO NOT FILL OUT THIS FORM. INSTEAD CALL 911, GO TO THE NEAREST ED, OR CALL 988 FOR ADDITIONAL CRISIS RESOURCES.
Name*

Legal First NameLegal Last Name
DOB*
Previous Names Used
Preferred Name
Social Security #*
Guardian Conservator If Applicable
Mailing Address*
Street Address if different
City*
State*
Zip Code*
*Phone #*
Email
example@example.com
Preferred Method of Contact*
May we leave a message with patient information on the preferred phone # above?*

YesNo
*Check the boxes that most accurately describe ethnic origin:*

Yes, Mexican, Mexican American, Chicano/aNo, Not HispanicYes, Puerto RicanYes, Other Hispanic OriginRefused
What is the primary language?*

American Sign LanguageArabicChineseEnglishFrenchGermanHindi/Indie LanguagesItalianRussianSpanishVietnameseOther
Check the boxes that most accurately describe race:*

American Indian or Alaskan NativeAsian IndianBlack or African AmericanChineseFilipinoGuamanian or ChamorroJapaneseKoreanNative HawaiianOther AsianOther Pacific IslanderSamoanVietnameseWhiteRefuse
INSURANCE INFORMATION
Primary Insurance*
Primary Insured Party Name*
DOB*
Relationship to Patient*
Policy*
Group*
Effective Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Secondary Insurance
Primary Insured Party Name
DOB
Relationship to Patient
Policy
Group
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
PRESENTING PROBLEM(S)
Medication being requested: esketamine (intranasal) clinic*

YesNo
Does client meet criteria for treatment resistant depression as defined by CMS? (two medication trials in two categories, during the most recent depressive episode)*

YesNo
Spravato treatment is contraindicated in patients with the following conditions:

Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation

History of intracerebral hemorrhage

Hypersensitivity to Esketamine, ketamine, or any of the excipients.
I have discussed this with my patient and they attest that they do not have any of the above stated conditions.*

Yes, the patient indicates NO history of these conditionsNo, the patient indicates a POSITIVE history of a condition listed above. Due to the above condition(s), this referral will be declined. Please discuss this with your patient and do not proceed with this referral.
Contraindication(s):
Does this client have a history of psychosis?*

YesNo
If Yes, please describe condition(s):
Is the client currently taking an oral antidepressant?*

YesNo
If yes, please list medication
Additional information that would be helpful to know about this referral:*
REFERRING PROVIDER INFORMATION
Referred by*
Practice Name*
Email address of referring provider*
example@example.com
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
To fully process this referral, please fax (802)258-3788 or email outpatient@brattlebororetreat.org a copy of:

1) Most recent medical note

2) Medication history

3) Front and back of the individual's insurance card.

Should there be any required information missing, a Practice Management Team member will reach out within 24 business hours to gather the information prior to being able to process the referral.
Should be Empty:

PRESENTING PROBLEM(S)