Patient Referral Form

Patient Referral Form

Please complete the following form to refer your patient to Collin Testing and Psychological Services for testing or therapy.
Referring Provider Name and Credentials
For example, Brian Collin, Psy.D.
Referring Provider Practice/Facility Name
Referring Provider Contact Email
example@example.com
Referring Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Provider Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
What services are you referring for?
Patient Insurance Plan

Other
If you indicated other, what insurance payer do they have?
Patient Full Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reason for Referral
Relevant Medical History or Current Diagnosis
Attach Supporting Documents (e.g., reports, test results)

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I certify that the information provided in this referral is true and accurate to the best of my knowledge. I have determined that the requested services are medically necessary for the diagnosis and/or treatment of this patient's condition. I have obtained the necessary consent from the patient (or legal guardian) to share this information with Collin Testing and Psychological Services for the purposes of care coordination. I understand that if consent is provided by the patient (or legal guardian), that I will be faxed a copy of the psychological evaluation upon completion of the testing process.*
Sorry, we are not taking the patient's insurance plan at this time.
We apologize, but we are no longer accepting United Healthcare, UMR, or GEHA at this time.
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