Professional Inquiry & Referral Form
Select the reason for your contact and provide your professional details so our team can route your referral or inquiry appropriately.
Professional Contact & Inquiry Details
Reason for Contact
*
Patient Referral
Care Coordination
Physician/Provider Inquiry
Hospital or Institution Inquiry
Professional Collaboration
Speaking/Educational Opportunity
Records/Documentation Inquiry
Other
Your Name
*
First Name
Last Name
Professional Title / Credentials
*
Organization / Practice Name
*
Type of Organization
*
Please Select
Physician Practice
Hospital/Health System
Mental Health Practice
Therapist/Counselor
School/University
Community Organization
Insurance/Health Plan
Government Agency
Other
Professional Email Address
*
example@example.com
Direct Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are You Referring a Patient?
*
Yes
No
Patient Referral Details
Patient Name
*
First Name
Middle Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
example@example.com
Is the Patient Currently Located in New York State?
*
Yes
No
Unsure
Primary Reason for Referral
*
Is the Patient Currently Receiving Psychiatric or Mental Health Treatment?
*
Yes
No
Unknown
Current Treating Provider(s)
Is Medication Management Being Requested?
*
Yes
No
Unsure
Insurance / Payment Method
*
Please Select
Insurance
Self-Pay
Unknown
Insurance Company
How Soon Is Care Being Requested?
*
Please Select
Routine
As Soon As Available
Time-Sensitive
Other
Details of Your Inquiry
Would You Like Hinds Psychiatric Services to Contact the Patient Directly?
*
Yes
No
Please contact me first
Supporting Records, Authorization, and Acknowledgments
Do You Have Supporting Records or Documentation to Provide?
*
Yes
No
Secure Supporting Records Upload
Upload a File
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of
Acknowledgments
*
I confirm that I am authorized to provide the information submitted through this form and, where applicable, to share patient information with Hinds Psychiatric Services for purposes of referral, treatment coordination, or healthcare operations.
I understand that submission of this form does not guarantee acceptance of a patient, establish a physician-patient relationship, or confirm an appointment.
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