Please note that any information you submit on this website may be considered Protected Health Information and may only be submitted with the prior authorization of your client or other guarantor defined under the Health Insurance Portability and Accountability Act (HIPAA) and HITECH Rule. Please do not proceed if you are unsure or have a question about this submission.

This form will allow us to schedule your appointment and contact you within the designated time frame to commence treatment at the earliest opportunity after the referral.