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This form is to be completed by a facility personnel to make direct referrals for a patient in need of our services. We appreciate you choosing us to provide services to your patients.
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If you prefer to submit a paper-form, please use link below to download PDF, fill it out, and email back to us at SUPPORT@LHPSYCH.COM
Email: TMS@LHPSYCH.COM Main Phone: (480) 565-6440 Main fax: (480) 454-1085
Email: LighthouseBilling@CUUBMED.COM Phone: (480) 485-9169
Email: Refill@LHPSYCH.COM Phone: (480) 870-8839
(This form is for existing patients, if you are a new patient please use our New Patient Enrollment Form)
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4001 E Baseline Rd Ste 204 Gilbert, AZ 85234
15300 N 90th St Ste 750 Scottsdale, AZ 85260