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. Format: (000) 000-0000.

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 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.

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

Format: (000) 000-0000.

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

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