Mental Health Referral Form

Contact Name* Contact Email*

Patient First Name* Patient Last Name* Patient DOB* Patient Phone* Patient Email Primary Referral Reason* -- Please Choose -- Psychiatry Therapy Testing TMS Additional Referral Reasons -- Please Choose -- Psychiatry Therapy Testing TMS -- Please Choose -- Psychiatry Therapy Testing TMS

Insurance Type* -- Please Choose -- Commercial EAP Medicaid Medicare Medicare Advantage Not Provided Self-Pay Other Tricare Primary Insurance* (Select 'Other' if patient's insurance is not listed) -- Please Choose -- AARP Health Care Options Absolute Total Care Absolute Total Care Medicaid Absolute Total Care Medicare ACPN Acuity Group Advent Health Aetna Aetna 100 Aetna Better Health Aetna Better Health Medicaid Aetna Choice POS PPO Aetna EPO Aetna Health Inc. Aetna Medicare HMO Aither Health Alliance Health Alliant One Health Allied Health Ambetter (Centene) America's PPO American Behavioral Amerigroup AmeriHealth Caritas Anthem Apostrophe Ascension Augusta University Aurora Health Care BCBS BCBS Advantage HMO BCBS Empire IL PPO BCBS Healthy Blue BCBS Medicaid BCBS NC State Health Plan BCBS NJ Horizon BCBS of South Carolina BCBS of Texas BCBS PPO BCBS PPO Compsych BCBS PPO POS EPO CHOICE BCCA BCN BHS BlueChoice Blue Cross Blue Shield Blue Cross Blue Shield of SC 401 Blue Cross Community Health Medicaid Blue Cross Complete Blue Cross of SC State Health 400 Blue Shield CA BonSecours SFMC Bristlecone Buckeye Health Plan Building Hope Cardinal Innovations CareATC Carebridge Carefirst BCBS Carelon Behavioral Health (Formerly Beacon Health Options) Carelon Behavioral Health Strategies (Formerly Beacon Health Strategies) Carelon Health Federal Services (Formerly Beacon - ValueOptions) Carelon Health IPA of California (CHIPA) (Formerly Beacon College Health IPA) Caremark Care Oregon CareSource Care Wisconsin First Carle EAP Carolina Complete Health Caterpillar PPO CBA CBA (subsidiary of BCBS SC) CCA CCHA CCHP CenCal Cenpatico Centivo N Holdings Chariho Regional School District CHO Cigna CIGNA 134 Cigna Medicare HMO Cigna POS OAP Clackamas Charter Alliance Cleveland Clinic CO Access Coal Alliance Coastal Harbor CO Judicial Department Common Ground Commonwealth Care Alliance Community Care Community Health Choice ComPsych Consociate Care CPCS Crested Butte State of Mind Curalinc Deaconess Health Plans Deaconess OneCare Dean Health DelTech DHHS DHS- Larimer County DHS- Weld County Digon System Disability Adjudication Services DMBA Dover BH DuPage EAP Works East Providence School Dept. EBMS Elevance (Formerly Anthem) EMI Health Empire BCBS Empire BCBS HealthPlus Employee Resource Center Employee Resource Systems Employer Health Care Alliance ESI EAP Evernorth (Formerly Cigna) Evolutions Healthcare Exceedent Fidelis First Choice First Health First Sun EAP Fort HealthCare Freedom Plan Friday Health Geisinger Health Plan Glendale Adventist Medical Center Group and Pension Administrators Haxtun Hospital District Headstrong Health Advocate EAP Health Alliance Healthchoice Healthlink Health Partners Health Payment Systems HealthScope Health UT Management Highmark BCBS HighmarkBS DE Highmark Health Options Hillsboro School District HMC HealthWorks Home Front Military Network Home State Health Humana Humana Choice PPO Humana Gold Plus HMO Humana Gold Plus HMO (Mcare) 793 Humana HMO WellMed IBH iCare Imagine360 Imagine Health Independence Blue Cross J.P. Farley JHHC John Hopkins University JRN Consulting Kaiser GA Kaiser NoCal Kaiser SoCal Kaiser WA KEPRO EAP Key Benefit Administrator (UofL Hospital) Lakeside Medical Lawyers Concerned for Lawyers Lifeworks EAP Livewell Solutions Lyra Health Magellan Magnacare Majoris MassHealth McLaren MedCost Medicaid Medicaid of Texas Acute Care Medical Assoc. Health Plan Medical College of WI Medical Mutual of OH (MMO) Medicare Medicare Part B 620 MediNcrease Meridian Meridian Health Meridian Health Medicaid Metropolitan Family Services EAP Mexia HHSC MGSD MHACO MHC MHN MHN Tricare MHS Mines EAP Mission Point Missouri Care Moda Health Modern Health Molina Healthcare Molina Medicaid Healthcare of SC MultiPlan Multnomah County School District Mutual of Omaha MVP MVP Healthcare ( Cigna Medicare) Network Health Plan Neuromotion Inc. (Mightier) New Avenues New Castle County Vocation Technical School District New Directions NMPN North Clackamas Schools Northern RI Collaborative Northshore LIJ Northwell Direct Northwestern Permanente Not Provided NPHO One Digital West (BRMS) OnTrak (Formerly Catasys) Optima Health Optum Optum Care dba Health Care Partners Oregon Episcopal School Orlando Health OSMA OSU Other Pacific Source PAI First Health (Preferred Blue ) Paramount Partners Behavioral Health Partners Direct Pathways Peach State Health Plan Peak Health Alliance PEHP PHCS Multiplan Physicians Health Network Pine Lakes PNOA PNW Boces Preferred Health Choices Preferred One Premera Premera First Priority Health Prisma Health Profile EAP Project 3125 Project Family Project Self Sufficiency Providence Quartet Health Quartz Quest Behavioral Health R3 Continuum Regal Medical Regence BC Regence WA RI International Rocky Mountain HP Sagamore Saint Francis LIFE SBSIPA Scripps Health Plan Second Wind Fund Select Health Self-Pay Sharp Health Plan Shasta Admin Services Signature Partners in Health (Innovation) SIHO Sisco Sisco (Imagin_MD) St. Francis Hospital St. Joseph's/Candler Health St Andrew Nativity St Rose School SummaCare Summit Counseling (CURE Childhood Cancer) Superior Health Plan SWHP TAMU TCHP The Nemours Foundation (AI Dupont Nemours) Thompson School District Total Care Network Town and Country Transitional Family Services Trestle Triad Tricare Tricare (HealthNet) Tricare (Humana Military) Tricare East Prime Tricare for Life Tricare West TriHealth Trillium Trilogy TriWest Tufts Twitter UCare MN UC Health UHC UHC (Golden Rule) UHC AARP Medicare UHC Choice UHC Choice Plus UHC Gold Advantage Plus UHC Medicare Advantage Assure (PPO) UHC WellMed UMR UNI Unicare United Behaviroal Health United Healthcare United Healthcare 113 United Healthcare UT United Health Medicaid-Medicaid MGD CARE Unity Point USFHP USMCO UUHP Vanderbilt University Vanderburgh County Vaya Health VES Veteran Affairs Vital Washington County Community Human Services WDW EAP WDW Workers Comp WEA Wellcare Wellpoint Westerly Public Schools Westwood Public Schools Whole Brother Mission Wilmington University WI Medical Society WISE Woodbridge School District WorkPlace Options EAP World Trade Center WPS Secondary Insurance -- Please Choose -- AARP Health Care Options Absolute Total Care Absolute Total Care Medicaid Absolute Total Care Medicare ACPN Acuity Group Advent Health Aetna Aetna 100 Aetna Better Health Aetna Better Health Medicaid Aetna Choice POS PPO Aetna EPO Aetna Health Inc. Aetna Medicare HMO Aither Health Alliance Health Alliant One Health Allied Health Ambetter (Centene) America's PPO American Behavioral Amerigroup AmeriHealth Caritas Anthem Apostrophe Ascension Augusta University Aurora Health Care BCBS BCBS Advantage HMO BCBS Empire IL PPO BCBS Healthy Blue BCBS Medicaid BCBS NC State Health Plan BCBS NJ Horizon BCBS of South Carolina BCBS of Texas BCBS PPO BCBS PPO Compsych BCBS PPO POS EPO CHOICE BCCA BCN BHS BlueChoice Blue Cross Blue Shield Blue Cross Blue Shield of SC 401 Blue Cross Community Health Medicaid Blue Cross Complete Blue Cross of SC State Health 400 Blue Shield CA BonSecours SFMC Bristlecone Buckeye Health Plan Building Hope Cardinal Innovations CareATC Carebridge Carefirst BCBS Carelon Behavioral Health (Formerly Beacon Health Options) Carelon Behavioral Health Strategies (Formerly Beacon Health Strategies) Carelon Health Federal Services (Formerly Beacon - ValueOptions) Carelon Health IPA of California (CHIPA) (Formerly Beacon College Health IPA) Caremark Care Oregon CareSource Care Wisconsin First Carle EAP Carolina Complete Health Caterpillar PPO CBA CBA (subsidiary of BCBS SC) CCA CCHA CCHP CenCal Cenpatico Centivo N Holdings Chariho Regional School District CHO Cigna CIGNA 134 Cigna Medicare HMO Cigna POS OAP Clackamas Charter Alliance Cleveland Clinic CO Access Coal Alliance Coastal Harbor CO Judicial Department Common Ground Commonwealth Care Alliance Community Care Community Health Choice ComPsych Consociate Care CPCS Crested Butte State of Mind Curalinc Deaconess Health Plans Deaconess OneCare Dean Health DelTech DHHS DHS- Larimer County DHS- Weld County Digon System Disability Adjudication Services DMBA Dover BH DuPage EAP Works East Providence School Dept. EBMS Elevance (Formerly Anthem) EMI Health Empire BCBS Empire BCBS HealthPlus Employee Resource Center Employee Resource Systems Employer Health Care Alliance ESI EAP Evernorth (Formerly Cigna) Evolutions Healthcare Exceedent Fidelis First Choice First Health First Sun EAP Fort HealthCare Freedom Plan Friday Health Geisinger Health Plan Glendale Adventist Medical Center Group and Pension Administrators Haxtun Hospital District Headstrong Health Advocate EAP Health Alliance Healthchoice Healthlink Health Partners Health Payment Systems HealthScope Health UT Management Highmark BCBS HighmarkBS DE Highmark Health Options Hillsboro School District HMC HealthWorks Home Front Military Network Home State Health Humana Humana Choice PPO Humana Gold Plus HMO Humana Gold Plus HMO (Mcare) 793 Humana HMO WellMed IBH iCare Imagine360 Imagine Health Independence Blue Cross J.P. Farley JHHC John Hopkins University JRN Consulting Kaiser GA Kaiser NoCal Kaiser SoCal Kaiser WA KEPRO EAP Key Benefit Administrator (UofL Hospital) Lakeside Medical Lawyers Concerned for Lawyers Lifeworks EAP Livewell Solutions Lyra Health Magellan Magnacare Majoris MassHealth McLaren MedCost Medicaid Medicaid of Texas Acute Care Medical Assoc. Health Plan Medical College of WI Medical Mutual of OH (MMO) Medicare Medicare Part B 620 MediNcrease Meridian Meridian Health Meridian Health Medicaid Metropolitan Family Services EAP Mexia HHSC MGSD MHACO MHC MHN MHN Tricare MHS Mines EAP Mission Point Missouri Care Moda Health Modern Health Molina Healthcare Molina Medicaid Healthcare of SC MultiPlan Multnomah County School District Mutual of Omaha MVP MVP Healthcare ( Cigna Medicare) Network Health Plan Neuromotion Inc. (Mightier) New Avenues New Castle County Vocation Technical School District New Directions NMPN North Clackamas Schools Northern RI Collaborative Northshore LIJ Northwell Direct Northwestern Permanente Not Provided NPHO One Digital West (BRMS) OnTrak (Formerly Catasys) Optima Health Optum Optum Care dba Health Care Partners Oregon Episcopal School Orlando Health OSMA OSU Other Pacific Source PAI First Health (Preferred Blue ) Paramount Partners Behavioral Health Partners Direct Pathways Peach State Health Plan Peak Health Alliance PEHP PHCS Multiplan Physicians Health Network Pine Lakes PNOA PNW Boces Preferred Health Choices Preferred One Premera Premera First Priority Health Prisma Health Profile EAP Project 3125 Project Family Project Self Sufficiency Providence Quartet Health Quartz Quest Behavioral Health R3 Continuum Regal Medical Regence BC Regence WA RI International Rocky Mountain HP Sagamore Saint Francis LIFE SBSIPA Scripps Health Plan Second Wind Fund Select Health Self-Pay Sharp Health Plan Shasta Admin Services Signature Partners in Health (Innovation) SIHO Sisco Sisco (Imagin_MD) St. Francis Hospital St. Joseph's/Candler Health St Andrew Nativity St Rose School SummaCare Summit Counseling (CURE Childhood Cancer) Superior Health Plan SWHP TAMU TCHP The Nemours Foundation (AI Dupont Nemours) Thompson School District Total Care Network Town and Country Transitional Family Services Trestle Triad Tricare Tricare (HealthNet) Tricare (Humana Military) Tricare East Prime Tricare for Life Tricare West TriHealth Trillium Trilogy TriWest Tufts Twitter UCare MN UC Health UHC UHC (Golden Rule) UHC AARP Medicare UHC Choice UHC Choice Plus UHC Gold Advantage Plus UHC Medicare Advantage Assure (PPO) UHC WellMed UMR UNI Unicare United Behaviroal Health United Healthcare United Healthcare 113 United Healthcare UT United Health Medicaid-Medicaid MGD CARE Unity Point USFHP USMCO UUHP Vanderbilt University Vanderburgh County Vaya Health VES Veteran Affairs Vital Washington County Community Human Services WDW EAP WDW Workers Comp WEA Wellcare Wellpoint Westerly Public Schools Westwood Public Schools Whole Brother Mission Wilmington University WI Medical Society WISE Woodbridge School District WorkPlace Options EAP World Trade Center WPS

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