MedLegal Referral Form
What are you submitting today?
*
Patient Referral
— I’m ready to submit a patient for a Minder evaluation
Referral Inquiry
— I have a question about a potential referral before submitting patient information
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Patient Contact Information
Please enter patient's name, phone number, and email (if available).
Patient's Name
*
First Name
Last Name
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Email
example@example.com
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What is the purpose of the evaluation?
*
Clinical
— for diagnosis and/or treatment planning
MedLegal
— to answer specific questions for a legal, insurance, claims, disability, or other third-party decision; no testimony or deposition
Forensic
— for a legal or third-party matter where the provider must be available for testimony or deposition
What is the context for the evaluation?
*
Workers’ Compensation
Personal Injury
Disability
Other
Workers’ Compensation Information
Please provide the following information if available.
Workers’ Compensation Claim Number
Date of Injury
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What kind of evaluation is needed?
*
Neuropsychological Evaluation
(e.g., TBI, cognitive, etc)
Psychological Evaluation
(e.g., PTSD, Anxiety, Depression, etc.)
Please describe the specific question(s) you would like the evaluation to address.
*
Example: Please evaluate the individual's current cognitive and psychological functioning following a reported TBI, clarify any applicable diagnoses, and determine the extent to which current symptoms and limitations are related to the reported injury. Please address functional impact, ability to return to work, and any relevant recommendations.
Please provide relevant clinical background and any special considerations for the evaluation
*
Example: Current symptoms or diagnoses, relevant medical or psychiatric history, language or accessibility needs, litigation status, or other relevant circumstances.
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Are you requesting a copy of the report with written results?
*
Yes, send a copy of the report by
email
Yes, send a copy of the report by
fax
No, a copy of the report is
NOT needed
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Email to send copy of the report
*
example@example.com
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Fax to send copy of report
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Want to upload supporting records?
Yes
No
Upload Supporting Records
Browse Files
Drag and drop files here
Choose a file
Please upload any relevant records, such as neuroimaging, prior neuropsychological or psychological evaluations, injury-related records, work-status documentation, or other materials relevant to the evaluation.
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of
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How can we help with your potential referral?
*
Please provide your question and any relevant details about the type of evaluation or services needed. Specify if you are interested in a neuropsychological or psychological evaluation. If you are ready to refer a patient for an evaluation and provide patient details, please hit back and select "Patient Referral" instead.
Who should Minder contact regarding this referral?
Referral Contact Name
*
First Name
Last Name
Referral Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Email
*
example@example.com
Referring/Authorizing Organization
*
Company or organization requesting or authorizing this referral or inquiry
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