Provider Referral Request (Merged 4/10)

We are currently unable to process Medicaid billing and cannot accept patients with Medicaid as their primary insurance.

Provider Information

Referring Provider Name*

Provider First NameProvider Last Name

Provider Phone Number*

This number will only be used for communication related to your referral.

Phone Number 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.

Referring Clinic Fax Number*

Please enter a valid phone number.

Patient Information

Patient Name*

Patient First NamePatient Last Name

Patient Date of Birth*

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Phone Number*

Patient Insurance Carrier*

Is the patient an Active-Duty Service Member?*

Which services would you like your patient to receive? *

If "Yes" for TMS services:

Has the patient been on at least 2 antidepressant medications?*

Has the patient been involved with talk therapy?*

Patient Diagnosis

Fill out a JotForm on the website: https://fccwellbeing.com/refer/

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