Thank you for considering Well Coast Medical Corporation for a referral. To make a referral, please:

1. Complete this Screening Form; AND
2. Fax the Face Sheet and Evaluation Notes to: 877-448-3551

Once this form has been submitted, we will contact the patient to schedule an intake appointment.

We currently accept referrals for cash-pay patients, and those covered by:

• Anthem PPO
• Aetna PPO
• Cigna PPO​
• Humana
• Lyra Health Plan
• Medicare
• Multiplan
• United Healthcare / Optum​​

We currently DO NOT accept referrals for patients intending to bill:

• Medi-Cal (even Blue Cross or Blue Shield)
• Blue Shield PPO (through Magellan only)
• Out-of-State Blue Cross or Blue Shield – unless the patient has verified that our providers are in-network.
• Any PPO plans not listed above, including: HealthNet.

Please be familiar with and abide by the following referral guidelines:

PATIENTS MUST NOT BE AT IMMINENT RISK

​If the patient is in imminent danger, DO NOT REFER. Instead, please advise them to go to the nearest emergency room or call 9-1-1. Needless to say, we are not a 5150 receiving facility. If patient is below 5150 threshold but is acute, please consider contacting Mobile Crisis in San Francisco (415)970-4000, or PERT in San Diego (9-1-1) to have them evaluate the patient’s risk level at your location or their residence.

PATIENTS MUST BE REFERRED FOR MEDICATION MANAGEMENT FOR MENTAL HEALTH / SUBSTANCE USE ISSUES.

Our psychiatric providers do not see patients solely for psychotherapy.

PATIENTS MUST BE APPROPRIATE FOR A SMALL PSYCHIATRIC PRACTICE

If the patient is anticipated to need frequent crisis management or higher levels of care, they would not be an appropriate referral.

Indicators of potential for excessive need include (but are not limited to):

• Comorbid serious neurological conditions such as dementia, advanced Huntington’s, advanced Parkinson’s;
• Two or more psychiatric inpatient hospitalizations within the past 12 months;
• Two or more suicide attempts within the past 12 months.

Patients with anticipated frequent crises and/or high need would more appropriately be referred to institutional agencies (such as UCSF and UCSD) who have resources to provide comprehensive care. That said, we are willing to accept infrequent referrals for psychiatric triaging, solely as a courtesy to our primary care provider partners.

PATIENTS MUST BE REFERRED FOR PSYCHIATRIC CHIEF COMPLAINTS THAT WE TREAT

• Alcohol/Substance use issues
• Attention-deficit/hyperactivity disorder
• Anxiety (panics, social anxiety)
• Binge eating disorder
• Bipolar disorder
• Depression and dysphoria
• Dissociative episodes
• Insomnia, sleep disturbance
• Mild cognitive impairment
• Obsessive compulsive disorder (incl. skin picking, hair pulling)
• PTSD, dealing with traumatic stress
• Psychosis, schizophrenia, schizoaffective disorder, prodrome symptoms
• Side effects of medications, and/or problems with withdrawals
• Traumatic brain injuries

If the problems or issues that need to be addressed are NOT listed above, we are not likely to be appropriate providers.

Again, once you have formalized the referral by submitting this Referral Form and faxing the Face Sheet and Evaluation / Progress Note, we will contact the patient.