Medication Management Request Form

Do you have a diagnosis or do you need an evaluation?*

Client's Full Name*

Client's Date of Birth*

Your Full Name (if not client)

Your Phone Number*

Insurance Network (please indicate if doing Private Pay or using Medicare, Medicaid, or EAP benefits)*

Previous psychiatric hospitalizations or rehabilitation programs?

If you are alright with us emailing you, please provide your E-mail Address*

By clicking SEND below you are consenting to sending personally identifying information. Please call if you prefer to provide it over the phone.

Attach Diagnostic/Health Info*

Attachments (0)

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Please take a picture of the front and back of your insurance card and email it to: office@knoxbehavioral.com

(Note: We can only process insurance cards received via email)

9129 Cross Park Drive, Suite 100, Knoxville, TN 37923