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Community Behavioral Health Professional Referral Form
Please answer every question in this form so our intake team can expedite your referral to allow for the patient's appointment to be made as soon as possible.
You may also send us a referral via our Direct Email: cbh@insyncdirect.com
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* Indicates required question
IDENTIFYING INFORMATION
Full Legal Name (As It Appears on Patient's ID)
*
Your answer
Patient's Date of Birth
*
MM
/
DD
/
YYYY
Patient's Social Security Number, if available
###-##-####
Your answer
Best Contact Number for Patient
*
(###)-###-####
Your answer
Address (Street Number, Street Name, City, State, and Zip Code)
Your answer
Patient's Email Address
Your answer
Race
White
Black or African American
American Indian or Alaskan Native
Asian
Native Hawaiian and Other Pacific Islander
Hispanic or Latinx
Two or More Races
Other:
Clear selection
Gender
Male
Female
Transgender Male
Transgender Female
Other
Prefer Not to Say
Clear selection
REFERRING PHYSICIAN OR OTHER PROVIDER CONTACT INFORMATION
Physician/Other Provider/Agency Name
*
Your answer
Physician/Other Provider/Agency Phone Number
*
(###)-###-####
Your answer
Physician/Other Provider/Agency Email Address
(###)-###-####
Your answer
Physician/Other Provider/Agency Fax
Your answer
INSURANCE INFORMATION
Please enter if available. If you do not have this information, please skip this section. We will contact the patient to obtain the information and verify insurance prior to scheduling their first appointment.
Insurance Carrier Name
Your answer
Insurance Carrier Plan
Your answer
Insurance Member ID Number
Your answer
Group Number
Your answer
Claims Phone Number
Your answer
Claims Address (including city, state, and zip)
Your answer
Policy Holder Name
Your answer
Policy Holder Date of Birth
MM
/
DD
/
YYYY
Policy Holder Social Security Number
Your answer
Secondary Insurance Carrier Name:
If none state N/A
Your answer
Secondary Insurance Carrier Plan:
Your answer
Secondary Insurance Member ID Number:
Your answer
Secondary Group Number:
Your answer
Secondary Insurance Claims Phone Number:
Your answer
Secondary Insurance Claims Address:
Your answer
Will the patient require a sliding scale payment option?
Yes
No
Clear selection
REASON FOR REFERRAL
Please explain the reason for the referral
*
Your answer
Clinic Location (select more than one if you are interested in referring for services available at different locations)
*
Cambridge
Centreville
Chestertown
Columbia
Denton
Easton
Princess Anne
Salisbury
Snow Hill
Required
Specialty Programs (Please indicate if you are interested in referring one or more of the following specialty services)
*
Intensive Outpatient Program (IOP) for Children
Outpatient Mental Health Clinic
Intensive Outpatient Program (IOP) for Adults
Substance Abuse and Mental Health treatment (including Medication Assisted Treatment)
Substance Abuse and Mental Health Intensive Outpatient or Partial Hospital Program
Bariatric Surgery Clearance (You will have to complete a CBT program to receive clearance)
Psychiatric Rehabilitation Program (PRP) only (please note this is only available to patients with Medicaid/Medical Assistance who meet criteria for severe mental illness)
Court Ordered Forensics (non-Substance) Treatment (Salisbury and Princess Anne only)
Anger Management for Adults
Child Respite Program
School Based Therapy (please indicate which school system in the Reason for Referral)
Targeted Case Management - Adults - Midshore Counties
Other:
Required
Patient's primary medical diagnoses
*
Your answer
Please list any of the patient's seasonal, food, or medication allergies
*
Your answer
Current Medications
*
Your answer
Thank you for completing this form.
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