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  • AMC EXTERNAL PROVIDER REFERRAL FORM-Outpatient Clinic

  • (Clinical notes can be provided through upload via this form at the bottom; fax (802) 258-3788 or email Outpatient@brattlebororetreat.org)

  • PLEASE CHOOSE SERVICE REQUESTED*

  • CLIENT INFORMATION

  • DOB:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

  • **If the patient has BCBS Out of State (Not BCBS VT) or Anthem Insurances, they will require a referral from the PCP**

  • DOB:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Expiration Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • DOB:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Effective Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Expiration Date:
     - -
    2 digit month, 2 digit day, 4 digit year
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  • PRESENTING PROBLEM(S)

  • REFERRING PROVIDER

  • Format: (000) 000-0000.
  • Submission Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Upon receipt of completed referral and clinical notes from recent visits, the next steps are as follows:

  • Patient responsibility:
    • Complete and return the program packet (assistance is available if requested)
    • Attach insurance card images
  • Brattleboro Retreat steps:
    • Financial eligibility will be reviewed within 24 business hours.
    • Clinical review to determine program eligibility.
    • Patient will be contacted with next steps.
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  • Should be Empty: