Referral for Patients

Referral for Patients
Thank you for contacting Creekside.

If you are experiencing a psychiatric emergency you should seek immediate help at your nearest emergency room. If there is an urgent need for care call our office.

We need some information so that we can assist you in getting the care that you need. This information will help us decide where to begin the evaluation process. All of our clinicians set their own new patient appointments. The information in this form will help with that process. Please complete this form and submit it electronically; or you can print the form and send it by mail; or FAX to our secure line (850) 476-2558.

You should also download our release of information form to help you begin to gather information about any previous treatment. And we can use this form to help coordinate care with your primary physician.

We will respond to your request for help but our review of this information does not establish a treatment relationship with any provider at Creekside. It is possible that your problems would be better addresssed in a different setting.

Your name *
How were you referred to Creekside?
Specific Creekside Professional Requested
This referral is for: *

Myself A child, adolescent, or college age Another adult

Age
Date of Birth *
Gender *
Maritial Status
Street Address *
City, State, *
ZIP code *
Home Phone
Other Phone
Preferred Daytime Contact Phone *
Employer
Position

Name *
Age
Date of Birth *
Gender *
Maritial Status
Street Address *
City, State *
ZIP code *
Home Phone
Other Phone
Preferred Daytime Contact Phone *
School and grade
Teacher/ Guidance
Mother
Age
Employer
Father
Age
Employer

Name
Age
Date of Birth *
Gender *
Maritial Status
Street Address *
City, State *
ZIP code *
Home Phone
Other Phone
Preferred Daytime Contact Phone *
School / Employer
School year

Describe the Problems That Cause Concern *
Tell Us About Any Previous Mental Health Treatment
Counseling Medications Hospitalizations

Medical Information
Primary Care Physician
Current Medications

Billing and Insurance Information

Patients are responsible for the cost of professional services provided at Creekside Psychiatric Center. To help you fullfill this obligation, we will clarify payment arrangements prior to starting treatment. We will make an effort to determine the amount of your personal financial responsibility.

Your health insurance may provide benefits for treatment. The staff at Creekside will work with you to determine available benefits. We are not responsible for the accuracy of information provided by your insurance company. The benefits may be controlled by a managed care company. There may be limits on frequency of visits, total number of visits, and amount of insurance payment per visit.

At your request, we will file insurance claims and submit bills to third parties. We have contracts with some insurance carriers and may accept assignment. You will be responsible for your deductible and co-payments according to your contract and payment is expected at the time of service. If you expect payment from other parties we will require full payment from you and assist you in getting reimbursed by the other party.

If your insurance company requires preauthorization for treatment, we will help you with this process. Usually, treatment is authorized for a limited number of visits. Insurance companies often require periodic review before authorizing continued treatment. You should monitor the number of authorized visits and any time limits. You are liable for the cost of unauthorized treatment unless prohibited by our contract with your insurance carrier.

An insurance company may require reports of your treatment and, in rare cases, may request a review of your entire record. We are sensitvie to your expectation that your treatment will be conducted with confidentiality. However, we cannot assure that confidentiality will be maintained when reports or records are submitted to insurance companies. You are encouraged to review reports prepared for third parties.
*

I do not plan to file my insurance Please file my insurance

Primary Insurance
Primary Insurance *
Policy Holder Name *
DOB *
Relationship to Patient *
Employer
Policy / Subscriber / Member No. *
Group No.
Mental Health Pre-Cert *

Area Code Phone Number
Customer Service

Area Code Phone Number

Secondary Insurance
Secondary Insurance
Policy Holder Name
DOB
Relationship to Patient
Employer
Policy / Subscriber / Member No.
Group No.
Mental Health Pre-Cert

Area Code Phone Number
Customer Service

Area Code Phone Number

Tertiary Insurance
Tertiary Insurance
Policy Holder Name
DOB
Relationship to Patient
Employer
Policy / Subscriber / Member No.
Group No.
Mental Health Pre-Cert

Area Code Phone Number
Customer Service

Area Code Phone Number

Any other information that will help understand your concerns:
Please type this word so that we know you are not a robot *
Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Should be Empty:

Referral for Patients

Primary Insurance

Secondary Insurance

Tertiary Insurance