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Peace of Mind, Inc. |
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817 West Front Street P.O. Box 2088 Lillington, NC 27546-2088 Phone: (910) 814 - 2197 Fax: (910) 814 - 2167 |
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PEACE OF MIND |
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817 West Front Street |
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Phone: (910) 814-2197 |
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P.O. Box 2088 |
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Fax: (910) 814-2167 |
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Lillington, NC 27546-2088 |
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REFERRAL FORM |
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Date: __________________________________ |
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Patient’s Name: ___________________________________________________________________ |
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Parent or Legal Guardian’s Name: ___________________________________________________________________ |
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E-mail address: ____________________________________________________ |
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Home Phone #: __________________________ |
Cell # __________________________________ |
Work # ______________________________ |
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Insurance Company: ___________________________________________________________________________________ |
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Insurance Company Phone: _________________________________________ |
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Policy # or ID: __________________________ |
Policy Group #: __________________________________________________________ |
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Policy Holder’s Name: ____________________ |
_________________ SS #: ________________________________________ |
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Policy Holder’s Address: ____________________________________________________________________________________________________ |
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Policy Holder’s Phone #: __________________ |
Policy Holder’s DOB: __________________________________________ |
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Policy Holder’s Employer: ___________________________________________________________________ |
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Physician’s Name /Signature: _________________________________________________________ |
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MD Telephone/Fax Number/E-mail: __________________________________________________________________________________ |
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Carolina Access Primary Care/NPI Provider Number: _____________________________________________________________________________ |
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Presenting Problem/Reason for Referral: _______________________________________________________________________________________ |
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_________________________________________________________________________________________________________________________ |
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Please fax completed referral forms along with HIPAA compliant cover page to: |
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(910) 814-2167 |
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OFFICE USE ONLY: |
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Insurance Authorization: ____________________________________________________________________________________________________ |
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01/2008 |
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