Referral Form

Self-Referral Form
Appointment Date
face sheet
Patient Name
Patient Identifier
Chosen Name: First
first
Last
last
Legal Name: First*
first
Last*
last
Birth Date*
MM-DD-YYYY
Pronouns
Gender

Cisgender femaleTransgender femaleCisgender MaleTransgender MaleNon-BinaryGender FluidQuestioningOther
Phone*
state
E-mail*
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Guardian Name: First
Last
Guardian Phone Number
Guardian Email
example@example.com
Guardian Name
Case Manager (If Applicable)
Case Manager Number
Notification Phone

Area CodePhone Number
Notification E-mail
Do you accept text messages?*

YesNo
Preferred Method of Communication*

PhoneTextEmail
By checking here you acknowledge that email and text communications will remain confidential, but cannot be considered encrypted with regard to HIPAA compliance once you receive them, as outlined in our Email/Text Communication Privacy Policy linked below.

Yes
Email/Text Commmunication Policy
General Availability for Scheduling
Intake appointments generally last 60 minutes
Referral Source
Desired Services

Medication ManagementDiagnostic EvaluationBirth Certificate Gender Marker ChangeSubstance Use TreatmentOther
Treatment Focus

DepressionAnxietyMood DisturbanceAttention/ConcentrationSleepAngerGrief/LossSubstance UsePTSDOther
Current Medications
Allergies
Current or Most Recent Prescribers
Current Pharmacy and Location
Additional Information
Do you have a provider preference at our organization? (does not guarantee availability)

NoneChase Cardurns PMHNP-BC
Insurance Information
Primary Insurance Carrier
Primary Insurance Carrier (Other)
**At this time we are only able to accept the following insurances: Mainecare, Anthem Blue Cross Blue Shield, Community Health Options, UMR, and Aetna. For all others we will accept payment at the time of appointment, and are able to supply an invoice reflecting CPT codes for insurance reimbursment or application to your deductible.**
Primary Insurance Policy Holder
Primary Insurance Policy Number
Primary Insurance Group Number
Primary Insurance Contact Number
From your insurance card
Copay (if applicable)
From your insurance card
Copy of Insurance Card

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Copy of Insurance Card
Gen
Secondary Insurance

Yes
Secondary Insurance Carrier
**At this time, we are not in network with Humana, Harvard Pilgrim, or Tricare. We are able to supply an invoice reflecting CPT codes for insurance reimbursment or application to your deductible.**
Secondary Insurance Carrier (Other)
Secondary Insurance Policy Holder
Secondary Insurance Policy Number
Secondary Insurance Group Number
Secondary Insurance Contact Number
From your insurance card
Copy of Insurance Card
Copy of Insurance Card

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Cancelof
Attach Additional Documents (optional)

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Cancelof
Policies and Consents
By checking this box, I consent to New Progress Psychiatry contacting my insurance carrier to obtain information on my behalf regarding coverage of services. I Agree*
Signature*

Clear
Guardian Signature (If Applicable)

Clear
LGBTQ+
Should be Empty:

Self-Referral Form

Insurance Information

Policies and Consents