Doctor Referral Form

How we can help

The provider presents us with their treatment plan, and we review it to ensure it meets standard level of care.

The patient’s treatment preference heavily influences our approval process
We help review medical insurance coverage and fulfill any state mandated processes are met in order to leverage medical insurance.

If the treatment plan provided by the provider requires an additional specialist, we collaborate with the provider to complete this plan.
If there is a gap in the patient’s care team, ie a primary care provider or mental health professional, we provide patients with names and/or referrals to these providers to ensure they have knowledgeable providers as a part of their overall care.

Date

MM

DD

YYYY

Referring Doctor Name

First Name

Last Name

Email

Phone

(###)

###

####

Patient Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Email

Phone

(###)

###

####

Patient Insurance Information

Initial Diagnosis

For Evaluation/Consultation of

Text

Please feel free to provide any additional information here

Thank you for choosing us to be a part of your patients care team. If you have records that you would like to share with us, please email them to hello@cccofnwa.com