Referring Physician Information

We ARE NOT CONTRACTED with Medicaid, Medicare, HIP or Marketplace Ins plans.

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Please fax office notes and insurance information to 812-401-8201 ATTN: Pam, Intake Coordinator *

Reason For Referral

Reason For Referral: *

Patient Information

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Insurance

We ARE NOT CONTRACTED with Medicaid, Medicare, HIP or Marketplace Ins plans.