Ptarmiganconnections.com
Ptarmigan Connections
3505E Meridian Park Lp, Ste 200
Wasilla, AK 99654
907-357-4400 (office)
907-357-4410 (fax)
REFERRAL FORM
Please provide as much of the following information as possible.
Please let your patient know we will contact them within 2 weeks.
|Date of referral: |
|Patient last name: First: MI: |
|Date of birth: |Gender: |
|Parent/guardian name: |Best contact phone(s): |
|Address: |Insurance Plan: |
| |Policy #: |
| |Policy holder name: |
|Referral Question |Category of Request (Check all that apply): |
|Please describe specific problems/symptoms and diagnoses: |Developmental Consultations |
| |High Risk/ Complexity Case Consultations |
| |Fetal Alcohol Spectrum Disorders (FASD) Diagnostic Evaluations |
| |Autism Evaluations |
| |Psychological and Neuropsychological Evaluations |
| |Psychiatric Medication Management |
| |Behavioral Health Counseling |
| |Group Therapy |
| |Speech and Language Therapy |
| |Feeding and Swallowing Management |
| |Other:_________________________ |
|Previous/current relevant health or mental health history (include duration of symptoms): |
|ICD-10 Code(s) (for insurance prior authorization): |
|Does the patient have any of the following limitations: (check) |
|Communication Language Vision Hearing Physical Disability History of Head Injury |
|Requesting provider: | Primary Care Provider Other |
|Best contact number: 907-357-4543 |Fax: 907-357-4533 |
| Referring Provider Signature: | |
| | |
|Today’s Date: | |
***Please send any recent chart notes, history and physical reports, or discharge summaries.
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