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

Patient Phone Number

Format: (000) 000-0000.

Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Which services would you like your patient to receive?

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.

Is the patient an Active-Duty Service Member?

Please note: Educational Assessments are not currently available in Florida.

Please note: Intensive Outpatient Program (IOP) is not currently available in Florida.

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