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