Sample Patient Referral Form

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Therapeutic Solutions Professional Counseling Group
201 S. McPherson Church Rd, Suite 202
Fayetteville, NC 28303
Office#: 910-916-6657 - Fax#:910- 920-2420
Patient Referral Form
Physican’s Office: _________________________
Client Name: ______________________________________
DOB: _______________
Client Contact #: _____________________________________
Concern and reason for referral: _______________________________________________________________________
Medications: Yes
No
Insurance/Payment Information (We currently accept the below named insurances. We also accept cash, debit and credit.
Please circle one: Tricare, Medicaid- Alliance, Medicaid- Sandhills, NC Health Choice, Aetna, Blue Cross Blue Shield
Person Responsible for Payment: _______________________________ Relationship to client: _____________________________
Primary Insurance
Secondary Insurance: _____________________________
Policy# (Social of Sponsor if Tricare):
Policy# (Social of Sponsor if Tricare):
DOB of Subscriber:
DOB of Subscriber:
___________________________
Counselor is requesting the following for “CLIENT” to receive Counseling Services:
1.______________________________________________
Physician’s Office Carolina Access NPI Number
2. ______________________________________________
Physician’s Printed Name
3.______________________________________________
__________
Physician’s Signature for Authorization
Date:
Please Fax Correspondence to:
Therapeutic Solutions Professional Counseling Group
201 S. McPherson Church Rd, Suite 202
Fayetteville NC, 28303
Fax: 910-920-2420

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