FAX 423-498-2001
Questions? 423-498-2000
Patient referral
Print, complete, and fax this sheet with relevant records and existing authorization.
Intake: Monday-Friday, 9:00 am-4:30 pm Eastern Time.
1 PATIENT AND CONTACT INFORMATION
Patient full name
Date of birth
Safe callback phone
Preferred contact method / time
Insurance / plan
Member ID
2 REQUESTED CARE
Addiction treatmentPsychiatric medication managementOtherFacility care coordination
Reason for referral / current care needs
Date care is needed / anticipated discharge date, if relevant
3 APPOINTMENT PREFERENCE
ChattanoogaClevelandSoddy-DaisyRinggoldDiscuss clinic with intake
In personTelemedicine
Psychiatric care is coordinated through Chattanooga. Intake confirms the visit plan.
4 REFERRING TEAM
Referrer name / title
Facility / agency
Direct phone
Return fax
Scheduling contact (if different) / direct phone
5 ATTACHMENTS
Current medication listClinical summary / discharge planInsurance informationExisting signed authorization