Cypress Care

Submit a Specialty Referral

Please use this electronic referral form to send new referrals to the Cypress Care Intake Specialist Team. If you already have a Sequoia login, click here.

Patient Information (* required)

* Client:
* Claim #:
* Last Name:
* First Name:
SSN:
* Address:
* Phone:
* City:
* State: Zip:
* (MM/DD/YYYY) Date of Birth:
* (MM/DD/YYYY) Date of Injury:
Employer:
ICD9:

Prescribing Physician

Name:
Address:
City:
State: Zip:
Phone:
Fax:

Insurance Information

* Adjuster:
Adjuster Email:
* Phone:

Case Manager Info

Name:
Email:
Phone:

Order Items(description and qty) / Notes /Additional Information