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REFERRAL FORM
Please Complete the following form and a counselor will be in touch with you shortly.
What type of claim is this?
State Fund
Self Insured
What referral type is this?
Behavior Health Intervention (BHI)
Accepted Mental Health Diagnosis on Claim (MH)
Employer
Date of Injury
Claim Number
Client First Name
Client Last Name
Client Telephone Number
Client Email Address
Client Street Address
Client Date of Birth
What is your relation to the cleint?
Client relation...
Self
VRC
Attending Provider
Medical Assistant
Other
Your Full Name
Your Phone Number
Your Email Adress
All Accepted and Denied Conditions (include ICD codes)
For BHI referrals, did the attending provider indicate approval / recommendation? (Please attach completed questionnaire, APF, or chart note.)
Yes
N/A - this is not a BHI referral
Conversation with Client?
Yes - I have spoken with the client about this referral and they are expecting a call from the therapist (or interpreter) to schedule.
N/A - this is not a BHI referral
For MH referrals, has treatment been authorized? (Please attach screen shot from CAC with the following psych codes authorized: 90832/90834/90837 (Therapy 30 min, 45 min, 60 min))
Yes
N/A - This is not a MH referral
Preferred method of treatment?
(limited in person session available)
In-Person
Telehealth
No preference
Primary Language
If English is second language, is it preferred that a therapist who speaks the client’s primary language be assigned?
N/A
Yes
No Preference
Name & Contact Info for Preferred Interpreter*
Claims Manager Name
Vocational Rehabilitation Counselor
Attorney Rep Name
Claims Manager Phone Number
VRC Phone Number
Attorney Phone Number
Attending Provider Name
Attending Provider Phone #
Attending Provider Fax #
Brief explanation of reason for referral (symptoms, situation/barriers, etc.)
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