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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