Referral Form – Franklin C. Brown, Ph.D., ABPP

Healthcare providers may use the following form to make a referral. This form utilizes industry standard encryption to protect patient data. However, if you would prefer to fax your request instead, you may use this form. Neuroimaging notes are also helpful to send when available.

I only provide neuropsychological testing (CPT Codes 96132, 96133, 96136, & 96137) for assistance in diagnosis, examining the cognitive impact of neurological conditions, and treatment planning. I do not provide traditional psychological evaluations or psychotherapy services.

Most insurance companies pay for neuropsychological testing for patients with suspected (e.g. memory loss) or known neurological difficulties. They typically do not pay for neuropsychological testing for primarily academic or some vocational reasons, even though it can be helpful for those difficulties. The patient will be informed prior to their appointment if the insurance will not cover the evaluation, and be given an option to pay privately.

Referring Provider's Name*
First Middle Last
NPI/UPN
Phone Number*
Fax Number*
Patient's Name*
First Middle Last
Insurance Company
Insurance ID#
Reason for Referral*
Additional Details*
Please provide additional details here.
Additional Records
You may attach a PDF file here with any relevant records (e.g., chart note, neuroimaging report, etc.).
Accepted file types: pdf.
Phone
This field is for validation purposes and should be left unchanged.

My relevant NPI numbers are:
Individual = 1710078621
Group (Franklin C. Brown, PhD, LLC) = 1801209838