LNI Referral

Patient Name *

First Name

Last Name

Date of Birth

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DD

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Patient Phone Number

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SMS Opt-In

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Yes

No

Service Request

Behavioral Health Intervention (BHI) - Initial services for physical diagnosis. Cannot have a MH diagnosis

Psychological Evaluation - Assess for MH diagnosis. Only physical diagnosis currently on claim

Psychological Treatment - Provided when an accepted/allowed MH diagnosis is already on claim

Psychiatric Medication Evaluation - Assess for MH diagnosis and discussion of psychotropic medications

Psychiatric Medication Management - Provided when accepted/allowed MH diagnosis is already on the claim

Psychoeducational Evaluation - Assess learning disabilities, intellectual functioning; usually for retraining

Neuropsychological Evaluation - Assess disability and provide recommendations for TBI patients

Your Relationship to Patient

Vocational Rehabilitation Counselor (VRC)

Attending Physician

Mental Health Provider

Other

Referring Person

First Name

Last Name

Referral Phone

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Claims Manager Name

First Name

Last Name

Claims Manager Phone

(###)

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Date of Injury

MM

DD

YYYY

VRC Name

First Name

Last Name

VRC Phone

(###)

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Attending Physician Name

First Name

Last Name

Attending Physician Phone

(###)

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Attending Physician Fax

(###)

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Attorney Name

First Name

Last Name

Attorney Phone

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