Provider Referral Request (Merged 4/10)

Start a Referral
Referring Provider Name

Provider First NameProvider Last Name
Provider Phone Number
This number will only be used for communication related to your referral. Format: (000) 000-0000.
Extension (if applicable)
Provider Email
Clinic Name
Clinic Address
Street Address
Clinic Address Cont.
Street Address 2
Clinic City
City
Clinic State
State
Clinic Zip Code
Zip Code
Clinic Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Clinic Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Clinic State
State
Patient Information
Patient Name

Patient First NamePatient Last Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient Phone Number
Format: (000) 000-0000.
Patient Address

Street Address

Street Address Line 2

CityState

Zip Code
Is the patient an Active-Duty Service Member?
Which services would you like your patient to receive?
Please note: Educational Assessments are not currently available in Florida.
Please note: Intensive Outpatient Program (IOP) is not currently available in Florida.
Patient Insurance Carrier
At this time, Family Care Center is unable to bill Medicaid in Florida, Tennessee, and Texas, or accept Medicaid as primary insurance in Colorado and Arizona.

In Florida, Tennessee, and Texas, services can still be handled on a self-pay basis. In Colorado, services can be billed to a primary insurance plan if you have one that's accepted by Family Care Center.
Photo of Front of Insurance Card

Cancelof
Photo of Back of Insurance Card

Cancelof
If "Yes" for TMS services:
Has the patient been on at least 2 antidepressant medications?
Has the patient been involved with talk therapy?
Why are you seeking psychoeducational testing?
Patient Diagnosis
Contact Owner
Fill out a JotForm on the website: https://fccwellbeing.com/refer/
Deal Name
Deal Pipeline
Deal Stage
gclid
utm_source
utm_medium
utm_campaign
GA Client ID
GA Session ID
Page URL
Ad Click ID
Should be Empty: