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EKM REFERRAL DOCUMENT
Please complete the following referral document. We will reach out to the client within 24 hours of receiving the completed form during business hours.
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* Indicates required question
Referring provider's name
*
Your answer
Referring provider's contact information & preferred method of contact
*
Your answer
Is the referring provider accepting new patients?
*
Yes
No
Client's full name
*
Your answer
Client's date of birth
*
MM
/
DD
/
YYYY
Client's contact information & preferred method of contact
*
Your answer
Does the client have insurance?
*
Anthem Blue Cross and Blue Shield New York (formerly Empire)
Oscar Health
United Healthcare
Oxford
Cigna
Aetna
Emblem Health
Medicare
Interested in Out-of-Pocket Costs
Reason for referral
*
Your answer
Does the client require a same-week evaluation?
*
Yes
No
Would the referring provider like to receive the client's treatment plan after each visit?
This includes, but is not limited to, treatment plan updates, medication information, and follow-up visit dates.
*
Yes
No
Would the Referring Provider Like to Schedule a Meeting Between the Client, the Referring Provider, and the EKM Provider?
*
Yes
No
Please provide any additional information:
Your answer
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