Referral Form NYU

Acknowledgement of referral receipt and insurance approval by DOC within 2 hours of submission.

To ensure eligibility the information below must always be referred for patients referred for:

  • Behavior Health
  • Psychiatric issues
  • Pain Management

Required information:

  • Date appointment is scheduled for Behavioral Health/Psychiatrist/Pain Management ( must be within 30 days)
  • Name, telephone number and address of Provider that will be rendering services
  • Confirmation that the service(s) requested is covered by the patient’s Insurance Plan ( ie substance abuse )