Meru Health Referral Form
Insurance Number / Member ID *
Member ID including all letters and numbers * Example: ZCS1000888
Insurance Group Number *
Please provide the name and contact information for the treating provider who will receive treatment summaries from Meru Health.
Inclusion
Exclusion
These criteria are meant as a guide. The Meru Health therapist will conduct a detailed phone screen to assess psychiatric symptoms and treatment program suitability.
This referral form complies with HIPAA.
If you have any questions, please contact our care team at support@meruhealth.com or via phone at (833) 940-1385.