Anavota Behavioral

Referral Form

New Patient Form

The intake process takes 3-7 business days, if you have not heard from our scheduling team in that time frame, please call us at 877-895-5486/832-834-3830 or email us at info.anvotabh@hush.com.

Relevant Medical History and Background Info:

I give Anavota Behavioral Health, PLLC/ABH, permission to build me in their system as a patient in our EMR system, for insurance verification of benefit eligibility checks, and for future scheduling outreach.

By checking this box you agree to receive recurring messages from Anavota Behavioral Health, PLLC. Reply STOP to Opt-out. Reply HELP for help. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. 

This letter and any documents attached to it are confidential and may contain information that is protected from disclosure by various federal and state laws, including the HIPAA privacy rule (45 C.F.R., Part 164) This information is intended to be used solely by the entity or individual to whom this fax is addressed. If you are not the intended recipient, be advised that any use, dissemination, forwarding, printing, or copying of this fax without the sender’s written permission is strictly prohibited and may be unlawful. Accordingly, if you have received this fax in error, please notify the sender immediately by return fax or call (608-305-8664), and then shred this document. Copyright 2002-2019, HIPAATraining.com

Provider information:

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