Comprehensive Neuropsychological Services



Comprehensive Neuropsychological Services

Brenda Parker, Ph.D.

Anne Boock Miller, Ph.D.

Phone 502-504-5231

Fax 949-862-8309

Referral Form

Patient Name: ___________________ Adult Child

Patient Phone Number: _________________ DOB: _________________

Parent/Guardian (if applicable): __________________ Parent Guardian POA

Parent/Guardian Phone Number (if applicable): ____________________

Reason for Referral: ________________________________________________________________________________________________________________________________________________ (If) Patient has a follow up scheduled with referring physician on: __________________

Type of Assessment: Neuropsych General Psych Developmental

Referring Physician’s Name: ___________________________________

Contact Name: ________________________ Direct Phone: _________________

Fax: ___________________

Please provide the following to process referral: front and back of patient insurance card, patient demographic page, and a copy of the most recent office visit summary including current diagnoses. Duplicate requests will only serve to delay processing.

Please fax this information to 949-862-8309.

We will contact the patient to schedule an appointment and inform your office of the date of assessment. Referrals are processed in the order they are received.

Completed reports will be faxed/mailed within 3-4 weeks of the appointment date.

Now Accepting Most Major Insurance Including: Medicare Humana

Anthem BCBS United HealthCare Optum Cigna

Aetna Anthem Medicaid KY Passport (ID# P0022962) Beacon Tricare

Tricare Prime (please submit referral) Humana Caresource Medicaid

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