Referral Form
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1REFERRAL FORM
From: __________________________
Fax: ___________________________
Pages (including cover): ___________
GROWING TREE
COUNSELING CENTER, PLLC
715 Fairgrove Church Rd SE, Ste 202
Patient’s Name: __________________________
Conover NC 28613
DOB: __________ Phone: _________________
Address: ________________________________
________________________________
Insurance (check one):
¨ Aetna
¨ Medicaid
¨
¨ Military One
Am. Healthcare
¨
¨ PHCS
BCBS
¨
¨ PPC
Cigna
PHONE:
¨ ComPsych
¨ Tricare
¨
¨ UBH
Health Choice
828-638-5907
¨
¨ Value Options
Inclusive Health
¨ Magellan
¨ Well Path
FAX:
¨ Medcost
¨ Other: ______________
828-322-2280
Notes: ____________________________________
EMAIL:
__________________________________________
__________________________________________
__________________________________________
WEB:
__________________________________________
STATEMENT OF CONFIDENTIALITY:
The information contained in this facsimile message is intended for
the sole confidential use of the designated recipients and may contain
confidential information. If you receive this information in error, any
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review, dissemination, distribution or copying of this information is
strictly prohibited, If you receive this information in error please
of
notify us immediately by telephone and return this information to us
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by mail or destroy. If you do not receive all pages as indicated please
call us to correct this mistake. Thank you.
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