Patient Information
We collect full demographics, insurance cards, photo ID, and guardian details directly from the patient after submission. Just enter what you have.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Biological Sex
*
Please Select
Male
Female
required for auth
Patient Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent / Guardian Mobile
Primary parent contact.
Format: (000) 000-0000.
Guardian Relationship
Please Select
Mother
Father
Legal Guardian
Other
Parent / Guardian Email
example@example.com
Referring Provider Name
*
The physician or NP/PA at the referring practice who is sending this patient.
Practice Address
*
Practice NPI Number
*
Physician Direct Callback Number
*
Practice Fax Number
*
For sending consult notes back.
Format: (000) 000-0000.
Preferred Contact Method
Please Select
Phone
Fax
No Preferred Method
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Insurance Information
Primary Insurance Carrier
*
Insurance Plan Name
Member ID Number
*
Group Number
Policy Holder Name
Policy Holder Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
If different from patient
Policy Holder Relationship
Please Select
Self
Parent
Spouse
Other
Secondary Insurance Carrier
Secondary Member ID
Does patient's plan require a PCP referral?
*
Please Select
Unknown — Hey Clinic will verify
No — PPO
does not require referral
Yes — HMO
referral required
PCP Name
PCP Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Information & Authorization
This section is submitted to the payor for prior authorization. The more detail you provide here, the faster authorization is approved.
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Clinical Information & Authorization
This section is submitted to the payor for prior authorization. The more detail you provide here, the faster authorization is approved.
Primary Diagnosis
*
Please Select
Adolescent Idiopathic Scoliosis (AIS) — thoracic (M41.119)
Adolescent Idiopathic Scoliosis (AIS) — thoracolumbar (M41.129)
Adolescent Idiopathic Scoliosis (AIS) — lumbar (M41.139)
Adult Idiopathic Scoliosis (M41.20)
Neuromuscular Scoliosis (M41.40)
Congenital Scoliosis (Q76.3)
Early-Onset Scoliosis under age 10 (M41.00)
Kyphosis — postural (M40.00)
Scheuermann's Kyphosis (M42.00)
Lumbar Spinal Stenosis (M48.06)
Cervical Spinal Stenosis (M48.02)
Spondylolisthesis — lumbar (M43.16)
Degenerative Disc Disease (M51.16)
Adult Spinal Deformity (M41.20)
Revision / Prior Spine Surgery (M96.1)
Second Opinion — scoliosis (M41.9)
Other
Secondary Diagnosis (optional)
Secondary ICD-10 (optional)
Service / Visit Type Requested
*
Please Select
New patient scoliosis evaluation
Surgical consultation
Second opinion
Bracing evaluation
Schroth PT evaluation
Complex / revision case
Anticipated CPT Code (optional)
Please Select
99243 — Moderate complexity consult
99244 — High complexity consult
99245 — High complexity surgical consult
97161 — PT evaluation low complexity
97162 — PT evaluation moderate complexity
Urgency
*
Please Select
Routine — within 2 weeks
Soon — within 5 days
Urgent — within 48 hours
Cobb Angle if known (optional)
Conservative Care Previously Tried (optional)
Please Select
None yet
Observation only
Boston TLSO brace
Rigo Chêneau brace
Physical therapy — generic
Schroth therapy
Bracing + Schroth
Surgery elsewhere
Other
Duration of Conservative Care (optional)
Please Select
N/A — none tried
Less than 3 months
3–6 months
More than 6 months
Clinical Notes / Reason for Referral
*
Has your office started prior authorization? (optional)
Please Select
No — Hey Clinic will initiate
Yes — already submitted
Auth Reference Number (optional)
Date Auth Was Submitted (optional)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Phone Used for Auth (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Provider Name
*
The physician or NP/PA at the referring practice who is sending this patient
Practice / Group Name
*
Practice NPI Number
*
Physician Direct Callback Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician Email
example@example.com
Office Coordinator Name
Coordinator Direct Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Please Select
Fax
Email
no preference
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Referral Order/ Records
Upload
Drag and drop files here
Choose a file
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Signature of referring provider
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Referral to Hey Clinic
Submit Referral to Hey Clinic
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