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REFERRING PHYSICIAN'S INFORMATION
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Father
Other
Mobile Phone
Home Phone
Email
Text
English
Spanish
Akan
Amharic
Arabic
Assamese
Awadhi
Azerbaijani
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Chewa
Chhattisgarhi
Chittagonian
Czech
Deccan
Dhundhari
Dutch
Eastern Min (inc. Fuzhou dialect)
French
Fula
Gan
German
Greek
Gujarati
Haitian Creole
Hakka
Haryanvi
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Hindi
Hmong
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Igbo
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Japanese
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Kannada
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BHPN
Blue Shield of California
Carefirst
Cigna
ComPsych
ESSC
Healthscope
Humana
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Kaiser Washington
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Molina
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Other
Message
By checking the box, you are agreeing to receive informational text message/SMS from the Brand Intercare Therapy. The frequency of messages may vary. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. Text HELP for help or reach out to us at info@intercaretherapy.com. Reply STOP to unsubscribe.
Terms & Conditions
and
Privacy Policy
.
How Can We Help?
I want to learn more
I am a new patient
I want to refer a patient
Or get in touch with us.
EMAIL
info@intercaretherapy.com
TELEPHONE
1 (888) 428-3223
REFERRING PHYSICIAN'S INFORMATION
PARENT / GUARDIAN INFORMATION
Mother
Father
Other
Mobile Phone
Home Phone
Email
Text
English
Spanish
Akan
Amharic
Arabic
Assamese
Awadhi
Azerbaijani
Balochi
Belarusian
Bengali
Bhojpuri
Burmese
Cebuano (Visayan)
Chewa
Chhattisgarhi
Chittagonian
Czech
Deccan
Dhundhari
Dutch
Eastern Min (inc. Fuzhou dialect)
French
Fula
Gan
German
Greek
Gujarati
Haitian Creole
Hakka
Haryanvi
Hausa
Hiligaynon/Ilonggo (Visayan)
Hindi
Hmong
Hungarian
Igbo
Ilocano
Italian
Japanese
Javanese
Jin
Kannada
Kazakh
Khmer
Kinyarwanda
Kirundi
Konkani
Korean
Kurdish
Madurese
Magahi
Maithili
Malagasy
Malay (inc. Indonesian and Malaysian)
Malayalam
Marathi
Marwari
Mossi
Nepali
Northern Min
Odia (Oriya)
Oromo
Pashto
Persian
Polish
Portuguese
Punjabi
Quechua
Romanian
Russian
Saraiki
Serbo-Croatian
Shona
Sindhi
Sinhala
Somali
Southern Min (inc. Hokkien and Teochew)
Sundanese
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Telugu
Thai
Turkish
Turkmen
Ukrainian
Urdu
Uyghur
Uzbek
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Wu (inc. Shanghainese)
Xhosa
Xiang
Yoruba
Yue (inc. Cantonese)
Zhuang
Zulu
PATIENT INFORMATION
Yes
No
Female
Male
Non-binary
Prefer not to answer
Unknown
Insurance Company
Aetna
Alameda Alliance for Health
Anthem Blue Cross/Blue Shield
Anthem Blue Cross of California
Beacon Health
BHPN
Blue Shield of California
Carefirst
Cigna
ComPsych
ESSC
Healthscope
Humana
Inland Empire Health Plan
Kaiser Colorado
Kaiser Mid-Atlantic
Kaiser Northwest
Kaiser Washington
LA Care Health Plan
Magellan
Managed Health Network
MCCP
Medicaid - Colorado
Medicaid - Maryland
Medicaid - Nevada
Medicaid - Oregon Health Plus
Moda Health
Molina
Multiplan
Optum/United Healthcare
PacificSource HealthPlan
Private Pay
School - LAUSD
School - Other
Teacher's HealthTrust
Tricare West
Other
Message
By checking the box, you are agreeing to receive informational text message/SMS from the Brand Intercare Therapy. The frequency of messages may vary. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. Text HELP for help or reach out to us at info@intercaretherapy.com. Reply STOP to unsubscribe.
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and
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.
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