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Rio Rio Grande Neuroscience | Dr. Jill Ryan and Associates
600 Central Avenue SE, Suite 221, Albuquerque, NM 87012 | (505)345-9288 | Fax (505)[email protected] | www.riograndeclinic.com
Jill Ryan, Ph.D., Clinical Neuropsychology
REFERRAL FORM – Please FAX to (505)212-0359
DATE: ______________ Referral Information:
Referring Doctor/Clinician: _________________________ Direct Phone:__________________
Referring Doctor/Clinician E-mail: ________________________________________________
Clinic Name: _______________________________________ Clinic Fax: ________________
Referral Question: ____________________________________________________________
__________________________________________________________________________
Referral for: ☐ Neuropsychological Evaluation ☐ Cognitive Retraining*
Please check all that apply: ☐ Memory loss ☐ Cognitive decline ☐ TBI☐ Intellectual Disabilities ☐ May need guardian ☐ ADD/ADHD☐ Learning Disabilities ☐ Other: __________________________
PLEASE PROVIDE ALL THAT APPLY:
Client Name: DOB: ___________ SS#: ____-___-____
Address: __________________________________________________________
City: _____________________ State: ________________ Zip: _______________
Phone: ________________________ E-mail: _____________________________
Appointment Contact: ____________________ Phone: ______________________
Relationship to Client: __________________ Primary Doctor: ________________________
Insurance – COMPLETE this section if insurance is to be considered as a payment source:
* Insurance is accepted for neuropsychological evaluation only.
Medicare Number: _____________________ Effective Date: ______________
Medicare Provider: ____________________________________________
Medicaid Number: _____________________ Effective Date: ______________
Medicaid Provider: ____________________________________________
Commercial/Other Insurance: __________________________________________________
Member Name: ________________________ Policy Holder Name: _____________________
Member #: ___________________________ Group #: _______________________________