Provider Referral Form
Please use this secure form to make a referral to Premier Behavioral Health Services. You may also send this information via fax 440-266-0257.
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Name
*
Practice/Clinic Name
*
Provider Email
*
example@example.com
Provider/Clinic Phone Number
*
Format: (000) 000-0000.
Do you want us to contact you directly or the patient?
Contact Provider
Contact Patient
Both
PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Patient DOB
*
Primary Insurance Carrier
*
Please Select
Aetna
Aetna Medicare
Anthem
Anthem Medicare
Cigna
Curative
EGP (Employer Group Plans – check with your HR/benefits manager)
Gravie
Meritain Health
Humana (Not HMO Plan)
Luminare
Medical Mutual
Medicare
Medicare Railroad
Mutual Health Services
Tricare / Humana Military
UMR
UnitedHealthcare
Optum
CareSource Marketplace
Self-pay ($200)
Patient/Parent Phone Number
*
Format: (000) 000-0000.
If minor, parent/guardian name
Reason For Referral
Individual Therapy
Medication Management
ADHD Assessment
Other
Additional Clinical Information
Submit
Should be Empty: