FL VR Customer Service Certification Referral
The Ringer Center of Excellence, Inc. Vendor ID #: VF432078660-001
Referral Date *
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Billing Code *
Class Start Date (Completed by Ringer)
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Counselor *
Counselor's Email *
Counselor's Work Phone *
Counselor's Cell Phone *
Referring Unit & Location *
CLIENT INFORMATION
Client Name *
Client Email *
Client Phone *
Client Address (City, State, Zip) *
Authorization # *
Client ID# *
Client Date of Birth *
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COMMENTS
If there anything we should know about your client that will help us serve them better? We practice HIPPA laws.
What would you like to share? *
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