Provider Referral Form | Life Changing Wellness and Treatment Center

📋 AHCCCS Contracted

We are a contracted provider for most AHCCCS managed care plans. We handle all prior authorization and billing coordination.

⚡ Fast Intake

Our intake team typically contacts referred patients within 24–48 hours of receiving a referral to schedule an assessment.

🤝 Collaborative Care

We coordinate with referring providers, PCPs, probation officers, and other agencies to ensure continuity of care.

📞 Direct Line

Questions about a referral? Call us directly at (602) 319-5155 or email us anytime.

👤 Referring Provider Information

Provider / Agency Name *

Provider Type *

Contact Phone *

Contact Email *

Organization / Practice Name

NPI Number (optional)

🏥 Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Gender

Patient Phone

Preferred Language

Patient Address

💳 Insurance & Authorization

Insurance / Payer *

Member ID / AHCCCS ID

Prior Authorization Number

Authorization Expiration Date

🧠 Clinical Information

Primary Diagnosis / Presenting Concern *

Requested Level of Care

ICD-10 Diagnosis Code(s)

Current Medications

Relevant Clinical Notes / Reason for Referral *

Current Safety Risk

Urgency of Referral *

📎 Consent & Coordination

Has the patient consented to this referral? *

Do you want to receive updates on this patient's care?

Additional Notes or Special Instructions

⚠️ Crisis Referrals: If your patient is in immediate danger, please call (602) 222-9444 (Maricopa County Crisis Line) or 911. Do not use this form for emergency situations.

✓ Referral submitted! Our intake team will contact you and the patient within one business day. For urgent referrals, please also call (602) 319-5155.