Refer a Patient to Klarity.

Complete the form below to refer a patient to our innovative care and mental health and wellness. We will contact the patient for scheduling.

1. Referring Provider Information

Referring Provider Name: *

Referring Practice / Clinic Name: *

Referring Practice Phone Number: *

Referring Practice Fax Number:

Referring Clinic Email Address:

2. Patient Information

First Name *

Last Name *

Date of birth *

Enter Patient's Date of Birth

Email *

Phone *

Address

Street Address

State

City

Postal Code

Patient Gender:

Insurance Provider (if known): *

3. Referral Details

Date of Referral Request: *

Urgency of Referral *

Service(s) Referred For: *

Relevant Diagnosis *

Include ICD-10 codes where possible for faster processing.

Reason for Referral

Previous Medication Trials *

Has the patient been informed of this referral? *

Yes

No

Maybe

What specific question or outcome do you hope to achieve with this referral?

4. Medical Records & Consent

Final steps to complete the referral.

Medical Records & Additional Information.

Please fax any relevant medical records or information to 855-277-4349 or email to [email protected].

Accuracy of Information for Referral *

I confirm that this referral information is accurate and submitted for coordination of benefits.

By submitting this form, I consent to receive SMS messages and/or emails from Klarity. To unsubscribe, simply follow the insturctions provided in our communications. Message & data rates may apply. Your information is secure and will not be sold to third parties.

Please feel free to call or text Klarity at 317-777-1034.