Encrypted Patient Referral Form
This HIPAA compliant form is to be used by another clinician or clinician's office to refer patients to Bay Area Neuropsychiatry. This form is not intended to be used by patients.
Referring Clinician Information
Referring Clinician Name: *
Referring Clinician Specialty: *
Referring Clinician's Contact Information: (phone number/email) *
Patient Information
Patient Name: *
Date of Birth: *
MM
/
DD
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YYYY
Email:
Phone Number: *
Insurance:
Reason for Referral: *
Communication

Has the patient been informed of the referral?

 *

Would you like to receive a copy of the intake note after the patient is seen?

 *

Would you like the evaluating psychiatrist to call the referring clinician to discuss the case?

 *
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This form was created inside of Bay Area Neuropsychiatry.