Provider to Provider Referral form (Wandering Pine Wellness)
This form is to be used by providers. You can use this to directly refer patients (instead of having them fill out our forms) to expediate the referral process. If you have urgent questions or concerns, please email info@wanderingpinewellness.com *Email is the best way to reach us, as we're typically with clients during the day and unable to answer the phone. 

FAQ

Q: How long will it take for my patient to hear back from you? 
A: We aim to respond to all incoming referral requests within 48 business hours. 

Q: Is this form HIPPA-compliant?
A: Yes. 

Q: Do you have availability?
A: Yes. We always have a provider with availability)
Sign in to Google to save your progress. Learn more
Your Name *
Name of Your Practice or Clinic (if applicable)
Patient's Full Name *
Patient's Phone Number *
Patient's Email
Which state does the patient live in? *
Required
Are you referring to a specific provider?
What insurance plan does the patient have? Please include the full name of the plan. Example: HPN Medicaid, not "HPN" or "Medicaid."
Referral Information.
Diagnosis (if known), reason for referral, etc. 
Optional: How did you hear about us?
Clear selection
Would you like us to contact you to follow up on this referral? 
If so, please include your contact information. 
If not, please answer "N/A"
 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Wandering Pine Wellness, PLLC.

Does this form look suspicious? Report

Google Forms