Freespira Provider Request for Services (RFS) Form

Freespira Request for Services (RFS) Form

Please complete the required fields and sign electronically. Once you hit Submit, we'll reach out the VA and Veteran to get authorized for treatment. Please note: This form is REQUIRED and MUST BE SIGNED by the requesting provider for further care to be rendered to a Veteran patient.
Section 1: Veteran Information
Veteran's Legal Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
VA Facility
VA Location
Section II: Ordering Provider Information
Requesting Provider's Name

First NameLast Name
NPI #
Specialty
Secure Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you an Indian Health Services (IHS) Provider?
Office Name
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ICD-10 Code
Provisional Diagnosis (Panic Attacks, Panic Disorder, and/or PTSD)
VA Authorization Number (This is the number assigned to the Veteran by the VA.)
Requesting Provider Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
The VA requires the most recent medical/clinical notes to be submitted along with the RFS form. Please fax the most recent medical note to 844.824.8779.
Should be Empty:

Freespira Request for Services (RFS) Form