Referral Form

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Referral Form

This referral form is meant to be used by medical other mental health providers and other agencies, organizations and professionals seeking to initiate outpatient services for clients in their care. If you are requesting to schedule a session for yourself do not complete this form, click the tab at the website that says schedule your session. If you have consent from the consumer you may also schedule their appointment by selecting the schedule your session tab.

All information submitted on this referral form is completely confidential, secure and encrypted.

Email *

Parents of adult children CANNOT initiate treatment on their adult child's behave due to CONFIDENTIALITY and HIPPA regulations. If you would like your adult child to engage in counseling then you will need to give them our information in order to have them initiate treatment. We will not follow up with referrals made if this is the case. *

I have read.

I am a referring provider and wish to proceed with making the referral.

We do not offer pre consultations or consultations? *

I have read and wish to proceed with making the referral

Referral Source: Name of the Organization, person making the referral and contact number. *

Do you have an active consent for release of information? *

No (If No please stop completing this form, complete a release of information and fax it to us.)

Yes: Please fax a copy to (336) 663-2906

Please complete the patient's information

First name: *

Last name *

Date of Birth *

YYYY

Home Address: (Please put the address that is on the insurance card) *

City *

State *

zip code *

Phone number *

Patients: email address *

Medication List *

How did you hear about the practice? *

Reason for seeking services? *

Insurance Information or EAP. Who is their insurance carrier or EAP carrier? *

Have you contacted your insurance to verify treatment is covered *

Yes

No I am using my EAP

No I am self pay

If you have not done so already please stop and contact your insurance provider. You need to verify that your session is covered, what your deductible is and what your copay is. You can find the number on the back of your insurance card. *

I have read

I will not be using my health care insurance I will be using my EAP benefit.

I will be paying out of pocket for my session.

Required

What questions should I ask my insurance provider? *

“Do I have mental/behavioral health coverage?”

If YES, continue. If NO, there is no need to proceed; other payment arrangements must be made. Please contact therapist to discuss payment options.)

“Is my preferred therapist , Samaria M Colbert MSW LCSW in network?” YES NO (If YES, go to In‐Network Coverage, If NOgo to question 3)tion 3

Your insurance company may ask for the NPI (national provider identification) of your therapist Samaria M Colbert NPI number is 1699077396 for Medicare recipients your NPI number is 1700313780. Or it maybe under, Kingdom Creative Counseling PLLC

Do I have Out‐of‐Network benefits?” YES or NO If YES, go to Out‐of‐Network benefits. If NO, there is no need to proceed; other payment arrangements must be made. Please contact the therapist with whom you want to work to discuss payments options.

What is my co‐pay amount? (co-pays must be paid in full at the time of your session)

Do I have a deductible?” YES or NO

If YES, “What is my deductible?” (A deductible is what you have to pay out of pocket BEFORE your insurance will pay.

Do I have an Out‐of‐Network deductible?” YES or NO

If YES, “What is my out‐of‐network deductible?"

This does not apply to me I will be using my EAP benefit.

This does not apply to me I will be paying out of pocket for my session.

If you are using your EAP benefit, you must have contacted your EAP provider and let them know you have selected provider: Samaria M Colbert or Kingdom Creative Counseling PLLC. Otherwise, you may have an unexpected out of pocket fee because you have not gotten authorization from your EAP provider BEFORE your session. *

I understand

This doesn't apply to me I am using my health insurance.

This does not apply to be I am self pay

Required

Have you gotten authorized from your EAP to see Samaria M Colbert MSW LCSW or Kingdom Creative Counseling PLLC *

Yes

This doesn't apply to me I am using my health insurance.

This does not apply to be I am self pay

Required

Did your EAP give you an authorization number? *

Yes if so please provide that number to your therapist at the time of your session.

No my EAP does not give authorization numbers but they did assure me that my session has been authorized.

This does not apply to me because I am using my health insurance.

This does not apply to me I am self pay

Subscribers name: *

Policy Number: *

Do you have a deductible? *

Yes

Maybe

What is your deductible?

Name of secondary insurance

Policy number for the secondary insurance

Emergency contact person (Name) *

Emergency contact person (Phone Number) *

I understand that if I am paying for my session out of pocket the session must be paid in full BEFORE my first session or my session will be canceled. You will be sent a invoice within 24 to 48 hours prior to your scheduled session. *

This does not apply to me I am using my health insurance.

This does not apply to me I am using my EAP

I understand.

Emergency contact phone number *

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Samaria M Colbert. I understand that I am financially responsible for any balance. I also authorize Kingdom Creative Counseling PLLC or Samaria M Colbert to release any information required to process my claims. By clicking on this form you are essentially authorizing us to bill your insurance. Checking in the box is, in essence, the equivalent to your signature. *

I understand and I do consent.

I am the referring provider.

Name: *

YYYY

Signature *

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