The Neuropsychology Center

Patient Referral Form

Referring Doctor/Specialty: ___________________________________________________________

Doctor’s Telephone #: _______________________________________________________________

Referring Diagnosis: _________________________________________________________________

Presenting Problem(s): _______________________________________________________________

Patient Name: _____________________________________________________________________

Date of Birth: ________ /________ / ________

Patient Address: ____________________________________________________________________

__________________________________________________________________________________

Patient Telephone #: home: (________ ) ________ - ________________

work/cell: ( ________ ) ________ - ______________

Insurance Company Name: ___________________________________________________________

Name of Insured Party: ______________________________________________________________

Insured’s Date of Birth: ______________________________________________________________

Insured’s Employer: _________________________________________________________________

Policy ID: _________________________________________________________________________

Group #: __________________________________________________________________________

Insurance phone # to verify benefits: (_________) ________ - _____________

*** the following information is optional ***

Name of Alternate Contact: ___________________________________________________________

Relationship to Patient: ______________________________________________________________

Alternate Contact Telephone #: (_________) ________ - _____________

Please fax to The Neuropsychology Center, 214 373-0762