Refer a Patient For TMS Services

Make a Referral

For urgent appointment requests, please call the clinic directly at (608) 719-0313

Please provide all required information. Missing information may result in delayed processing of this referral. We may contact the patient directly for additional information, please notify the patient of this referral.

1. Patient First Name*

2. Patient Last Name*

3. Patient DOB*

4. Patient Phone*

5. Patient Email*

6. Patient Address*

7. Preferred Clinic to Receive Services*

Patient Insurance Information

1. Primary Insurance Carrier Name*

2. Member ID # / Subscriber ID #*

3. Group Number*

4. Does the patint have a seconday / supplemnt insurance plan?*YesNo

5. Secondary Insurance Carrier Name:*

6. Member ID # / Subscriber ID #*

7. Group Number*

Provider Information

1. Provider Full Name (First, Last, Credential)*

2. Provider NPI*

3. Clinic/Practice/Institution Name*

4. Provider Address*

5. Clinic/Office Phone*

6. Clinic/Office Phone*

7. Clinic / Office Fax*

8. Name of Contact Person within your office*

Records Request

To expedite the referral process, we request the following records

Insurance Card(s) – Copies of Front and back of card(s)
Progress Note from most recent follow up visit.
Note from Initial Evaluation.

1. The requestd record will be provided as listded below*FAX OPTION: Requested Reccords will be faxed to (608) 713-9647, ATTN: TMS StaffUPLOAD OPTION: Records will be uploaded via this formNo records will be sent

Front of Insurance Card*

Upload supported file (Max 5MB)

Back of Insurance Card*

Upload supported file (Max 5MB)

Most Recent Progress Note*

Upload supported file (Max 5MB)

Initial Evaluation*

Upload supported file (Max 5MB)

I acknowedge that the information provided above is acurately represents the patient, myself, and referal for TMS Services at Collaoraive Solutions in Psychiatry.