Welcome!
Thank for you for your interest in our clinic. We look forward to working with you. Like many other medical services, a request for our services must be made by a licensed clinical/medical practitioner. Please work with your medical providers to access our services; we do not accept self-referrals. You may print out and take a copy of our referral form to your doctor. Please ask him/her to fax copies of medical records and insurance information along with the completed form and a signed prescription.
The Process:
Once we have received complete information, the request will be reviewed by one of our doctors regarding appropriateness for our clinic. If so, we will then schedule the appointment and contact you by mail to notify you of the date and time. Due to high demand for our services at this time, we are scheduling patients four to six months out. Please be patient as we work to get you in.
Once you have received a letter from us confirming an appointment you may call the clinic to be added to our cancellation list. If you do not receive a letter from us (please allow six weeks from initial request for processing) please follow up with the referring provider; he/she will have been contacted by one of our doctors if we were not able to assist you for any reason.
Urgent & Emergent Requests:
Urgent requests are evaluated by our Clinical Director for medical necessity and must be accompanied by supporting documentation, ie., records, history, etc. Priority of scheduling urgent requests is given for the following: scheduled brain surgery, scheduled initial radiation treatment and scheduled initial chemotherapy treatment.
CNS REFERRAL FORM:
Download, Complete and FAX to: 505-272-8316
PDF Format
AUTHORIZATION TO REQUEST HEALTH INFORMATION FORM:
Download, Complete and FAX to: 505-272-8316
MsWord Format
PDF Format
AUTHORIZATION TO DISCLOSE/SHARE HEALTH INFORMATION FORM:
Download, Complete and FAX to: 505-272-8316
MsWord Format
PDF Format